What Is a Soap Note?

Physicians make medical records each time a patient visits the office. There are various formats for physicians to document the contents of the visit. SOAP notes are a uniform way to organize patient records.

Subjective

• The "S" in SOAP stands for subjective. Subjective notations are the comments that the patient gives to the doctor or nurse about the reason for the visit. This is where the patient history is recorded as well.

Objective

• The "O" in SOAP stands for objective. Objective notations are the findings that a physician discovers upon examination.

Assessment

• The "A" in SOAP stands for assessment. The assessment is the determination that the physician makes about the objective findings. This is where the physician would notate a diagnosis.

Plan

• The "P" in SOAP stands for plan. The plan is the physician's recommended course of treatment.

Benefits

• SOAP notes make accessing and locating information quick and efficient.