What does the acronym SOAP stand for in medical documentation?

The acronym SOAP is a widely used framework in medical documentation, especially in the context of patient evaluations and treatment planning. It stands for Subjective, Objective, Assessment, and Plan.

Subjective refers to the information provided by the patient regarding their symptoms, feelings, and experiences, which may include their personal account of the situation and any pertinent history. This part captures the patient's perspective and is critical for understanding their condition.

Objective entails the measurable, observable data collected during a physical examination, diagnostic tests, and other scientific assessments. This information is factual and can be quantified, such as vital signs or lab results, providing a basis for the clinical evaluation.

Assessment is the clinician's interpretation of the subjective and objective findings, leading to a conclusion about the patient's condition. It synthesizes the information to determine the diagnosis or severity of the issues the patient is facing.

Plan consists of the strategy for managing the patient's condition. This can include prescribed treatments, further diagnostic tests, referrals to specialists, or follow-up appointments. It outlines the steps that healthcare providers will take to address the patient's needs effectively.

The acronym is instrumental in maintaining organized and efficient records in healthcare, facilitating communication among professionals and enhancing the continuity of care.