Each stage of information-gathering signified by a letter in the acronym SOAP is essential to good care. Here is a basic breakdown of this documentation format:
- Subjective: A patient’s description of a Chief Complaint.
- Objective: The informed observations of a health care practitioner.
- Assessment: Diagnosis and etiology of the Chief Complaint and other factors.
- Plan: A professional plan to treat the Chief Complaint and other concerns.
The Subjective portion of a SOAP note accounts for the patient’s Chief Complaint, History of Present Illness, Past Medical History, Family History, Social History and a Review of Systems.
Subjective and Objective observations may be guided by other mnemonic devices such as OLD CHARTS for Onset, Location, Duration, Character, Alleviating and Aggravating Factors, Radiation, Temporal Pattern, and Severity.
Objective observations start with the age, gender and general appearance of the patient and proceed through recorded measurements of vital signs. Body temperature, weight, body mass index, glucose level, heart rate, blood pressure and respiratory rate are often included in SOAP notes.
The Assessment portion of a SOAP note summarizes main symptoms and sets forth a diagnosis, attempting to account for the etiologies and risk factors associated with a condition. Each note concludes with a Plan to treat concerns. A SOAP note can stand alone as proof of consultation and professional recommendation of care or be used in long-term assessments of health conditions based on past documentation.