What does the acronym SOAP stand for in health care documentation?

The acronym SOAP stands for Subjective, Objective, Assessment, Plan, and it is a widely used method in healthcare documentation that helps organize patient information in a systematic way.

"Subjective" refers to information shared by the patient regarding their personal feelings, symptoms, and experiences. This can include verbal reports from the patient about their health and wellbeing.

"Objective" consists of measurable data such as vital signs, physical examination findings, and laboratory results that healthcare professionals gather during an assessment. This information is factual and can be tested or observed.

"Assessment" is the professional judgment of the healthcare provider, synthesized from the subjective and objective data collected. It involves diagnosing the patient’s condition or identifying issues that need to be addressed.

"Plan" outlines the proposed course of action based on the assessment. This could include medications, treatments, further testing, referrals, or patient education strategies.

Using the SOAP format enhances communication among healthcare providers and ensures that important aspects of the patient's care are recorded comprehensively. This structure also supports a clear and consistent approach to patient management and documentation.