SOAP Notes
SOAP Notes are a structured method used by healthcare professionals to document patient information. The acronym stands for Subjective, Objective, Assessment, and Plan. Each section serves a specific purpose: the Subjective section captures the patient's personal experiences and symptoms, while the Objective section includes measurable data such as vital signs and test results.
The Assessment section provides the healthcare provider's diagnosis or clinical impression based on the information gathered. Finally, the Plan outlines the proposed treatment, further tests, or referrals needed. This format helps ensure clear communication and continuity of care among healthcare providers.