What do the letters in SOAP stand for in a medical context?

In a medical context, SOAP stands for Subjective, Objective, Assessment, and Plan. This framework is used by healthcare providers to organize and document patient information in a structured manner.

• Subjective refers to the information that the patient provides, such as their symptoms, feelings, and personal perspective on their condition. This part of the note captures the patient's narrative and helps clinicians understand the patient's experience and concerns.

• Objective includes the data gathered from physical examinations, laboratory tests, and diagnostic imaging. This section contains measurable and observable information that can be confirmed by the healthcare provider.

• Assessment involves the clinician's interpretation of the subjective and objective information, leading to a diagnosis or a summary of the patient's condition. This reflects the healthcare provider’s clinical judgment and reasoning.

• Plan outlines the recommended treatment or management strategies based on the assessment. This may include further tests, medications, referrals, or follow-up appointments.

The structure provides a clear method for documenting patient interactions and ensures that all relevant aspects of the patient's condition are considered and addressed in a systematic way.