What is a patient encounter SOAP note?


Quick Answer

A SOAP note is a method of documentation employed by medical professionals to create a patient's chart, according to EMRSoap. SOAP stands for subjective, objective, assessment and plan. These four sections make up a SOAP note.

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Full Answer

The subjective section is a narrative of the patient's chief complaint or the reason why the patient presents, states EMRSoap. The subjective section includes information such as the onset of the complaint, the severity and quality of the complaint and the chronology of the complaint. The narrative also discusses additional symptoms and treatments employed for the chief complaint.

The objective section includes objective facts about the patient's condition, explains EMRSoap. Physical examination findings, vital signs, laboratory values and measurements appear in the objective section. The assessment section is a list of the patient's diagnoses. The diagnoses are listed as of the medical visit on the date the note is written. The plan section describes the medical professional's planned treatment for the patient. The treatment may include ordering labs, prescribing medications, making referrals and conducting procedures. SOAP notes provide structure and rigor to medical documentation. This is important to minimize the chance of medical error. SOAP notes also provide a means of effective communication between practices.

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