SOAP is an acronym for Subjective, Objective, Assessment and Plan. A medical SOAP note is a method of charting information, appointments and progress with a patient. The notes are kept in the patient's chart for future reference and to track overall progress. The SOAP note includes the subjective (what the patient is presenting with), objective (what the medical professional observes), assessment (diagnosis or declaration of facts presented) and the plan (plan of treatment for the presenting issue). To properly write a SOAP note, you must learn the parts of the note and how to use them to chart patient progress.
- Skill level:
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Things you need
- Scrap paper
- Progress note (compliant with your office's charting requirements)
Write out your subjective section. Include the reason for the patient's visit to your office or clinic. List all of the symptoms and observations of the patient in this section. Anything the patient informs you of should be included in your subjective.
Write out your objective section. Include your own observations and those of your colleagues who have seen the patient. Include the patient's vital statistics, any physical measurements that have been taken and visible symptoms.
Write out your assessment. Include test results such as X-rays, diagnosis of any diseases or conditions and any findings that explain the patient's presenting issues.
Write out your plan. Include the plan of action for any treatment, any treatment that was provided at the time of care and the plan for follow-up appointments or referrals to other providers.
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