SOAP stands for Subjective, Objective, Assessment, and Plan. A SOAP note is a method of documentation used by healthcare providers, particularly in fields like medicine, nursing, and allied health professions, to organise patient information in a systematic format. The acronym "SOAP" stands for:
Subjective: Patient-provided information like complaints, symptoms, and medical history.
Objective: Observable data from tests, measurements, and examinations.
Assessment: Healthcare provider's analysis of the patient's condition, including diagnoses.
Plan: Outline of treatment, including medications, tests, referrals, and follow-up instructions.
SOAP notes ensure comprehensive documentation, aiding communication among healthcare teams and serving as a legal patient care record.