In a patient encounter note, what does the acronym SOAP stand for?

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. This framework is widely used in clinical settings for documenting patient encounters.

In the subjective section, the clinician records the patient's personal experience, including their symptoms, feelings, and any relevant history that the patient shares. This aspect emphasizes the patient’s perspective and is vital for understanding their condition.

The objective section includes measurable or observable data that the clinician gathers during the examination. This may involve vital signs, physical examination findings, and results from laboratory tests or imaging studies. The objective data provides a factual basis for evaluating the patient's health status.

The assessment section is where the clinician synthesizes the information from both the subjective and objective findings to form a diagnosis or clinical impression. It reflects the clinician's professional judgment regarding the patient's condition.

Lastly, the plan outlines the proposed interventions. This can include medication prescriptions, referrals to specialists, further diagnostic testing, or recommendations for lifestyle modifications. The plan is essential for guiding the patient's treatment and follow-up care.

This structured approach facilitates clear communication among healthcare providers and ensures a comprehensive evaluation of the patient's health, making it an essential tool in primary care practice.