What does the acronym SOAP stand for in medical documentation?

The acronym SOAP in medical documentation stands for Subjective, Objective, Assessment, and Plan. This structured method is used by healthcare professionals to organize and document patient information effectively.

'Subjective' refers to the information provided by the patient regarding their symptoms, feelings, and perceptions about their health. This part captures the patient's personal experience, which is crucial for understanding their condition.

'Objective' includes measurable and observable data collected during the examination. This could involve vital signs, physical examination findings, and laboratory test results, providing a factual basis for the medical professional's evaluation.

'Assessment' is the section where the healthcare provider interprets the subjective and objective information to make a clinical judgment about the patient's condition. It often includes a diagnosis or a differential diagnosis.

'Plan' outlines the recommended course of action based on the assessment. This may consist of further tests, treatments, referrals, patient education, and follow-up appointments.

This comprehensive approach aids in ensuring clear communication among healthcare providers, promotes continuity of care, and facilitates understanding of the patient's progress over time.