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