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Example of SOAP Note

The letters SOAP stand for Subjective, Objective, Assessment, and Plan. SOAP notes are actually structural definitions of health notes written for patients by health care providers. SOAP notes contain a lot of information, and the structure is used as both a quality control and an organizer for providers.

The subjective element contains notes of the patient's condition in a progressive or narrative form.

The objective element contains test results, pathology, vital signs and similar data.

The assessment element includes diagnoses and possible alternate diagnoses,forming a holistic approach to the diagnostic options.

The plan is based on the other elements to a large extent and provides a guide to intended treatment.

Examples of SOAP Note:


http://en.wikipedia.org/wiki/SOAP_note
http://www.marshall.edu/commdis/formsetc/soap-notes.pdf