What does the acronym "SOAP" stand for in documentation?

The acronym "SOAP" stands for Subjective, Objective, Assessment, and Plan. This framework is widely used in healthcare documentation to ensure a structured and comprehensive approach to patient assessments and care planning.

The "Subjective" component involves the patient's personal experiences, feelings, and symptoms as expressed in their own words. It captures the patient's perspective and can include details such as their current complaints and medical history.

The "Objective" section consists of observable and measurable data gathered during the examination. This can include vital signs, lab results, and physical examination findings, providing a factual basis for assessment.

The "Assessment" part represents the healthcare provider's interpretation of the subjective and objective data. It may include the clinician's diagnoses or reflections on the patient's condition.

Finally, the "Plan" outlines the strategy for addressing the patient’s needs, which may include further tests, treatments, referrals, or education.

Overall, using the SOAP format promotes clear communication among healthcare providers and helps ensure that essential information is well-organized and easily accessible. This systematic approach is crucial for maintaining high-quality patient care and improving outcomes.