What does SOAP stand for in documentation?

In the context of medical documentation, SOAP stands for Subjective, Objective, Assessment, and Plan. This framework is widely used by healthcare professionals to organize patient information systematically.

The "Subjective" component refers to information reported by the patient, including their feelings, perceptions, symptoms, and personal experiences regarding their health condition. This might include a patient's description of pain or discomfort, which provides insight into their subjective experience.

The "Objective" section includes measurable or observable data collected by the healthcare provider during examinations, such as vital signs, physical exam findings, lab results, and other diagnostic information. This data is crucial for an accurate and comprehensive understanding of the patient's condition.

The "Assessment" part is where the healthcare provider synthesizes the subjective and objective findings to identify the patient’s condition or progress. It reflects the clinician's diagnosis, conclusions, or an evaluation of the patient's status.

Lastly, the "Plan" outlines the proposed interventions, treatments, or further tests required for the patient's care. This could include medications, referrals, follow-up appointments, or specific procedures aimed at addressing the patient’s needs.

This structured approach helps ensure that patient information is clearly communicated and provides a consistent method for documenting patient encounters in clinical settings.