What does SOAP stand for in medical documentation?

The acronym SOAP in medical documentation stands for Subjective, Objective, Assessment, and Plan. This structured method is widely used by healthcare professionals to organize patient information effectively and to facilitate communication among providers.

• Subjective refers to the information reported by the patient, such as symptoms, experiences, and feelings. This part captures the patient's own perspective, allowing for a more personal understanding of their health status.

• Objective includes observable and measurable data collected during the physical examination or from diagnostic tests. This provides concrete evidence of the patient's condition and is essential for supporting clinical decisions.

• Assessment is the healthcare provider's interpretation of the subjective and objective findings. It reflects the clinician’s thoughts on the patient’s diagnosis and provides insight into the clinical reasoning process.

• Plan outlines the proposed course of action for the patient, including further tests, treatments, medication, or referrals. It ensures that the patient receives comprehensive care tailored to their needs.

This structured format enhances clarity and continuity of care, making it a critical component of effective medical records. Other options do not accurately reflect the widely accepted terminology and methodology used in medical documentation, which is why they do not fit the definition of SOAP.