Subjective objective assessment plan, or SOAP, is a note-taking format used by health care facilities, according to the University of North Carolina School of Medicine. The subjective section includes the symptoms the patient complains of, and the objective section contains test results and exam results. The assessment section includes the health care professional's conclusions and impressions based on the first two sections. The plan section explains the next steps, including treatment, medication and further testing.Continue Reading
SOAP notes should be able to stand on their own, with no additional notes or forms, according to the National Board of Osteopathic Medical Examiners. The subjective section should include pertinent information from the patient's medical and personal history. The objective section is strictly limited to the procedures the professional performs during the visit. Physicians should add three possible diagnoses to the assessment section. The most plausible diagnosis should be first.
Most SOAP notes are written for other health care professionals, asserts The Monday Clinic. For efficiency, the notes should be concise and contain only relevant information. Health care professionals should avoid using acronyms when possible to eliminate confusion. Each SOAP note must contain the physician's name and title, along with the date and time.Learn more about Diagnostics & Imaging