What is the purpose of the “SOAP” note format in medical documentation?

The purpose of the “SOAP” note format in medical documentation is to provide a structured way to document patient encounters. This format facilitates clear communication among healthcare providers by organizing information into four distinct sections: Subjective, Objective, Assessment, and Plan.

The Subjective section includes the patient’s personal experience and feelings about their condition, which helps in understanding their perspective. The Objective section contains measurable and observable data such as vital signs and physical examination findings. The Assessment section is where the healthcare provider synthesizes the information and makes a judgment about the patient's condition, while the Plan outlines the next steps for treatment, further testing, or referrals.

Using this structured format ensures that all relevant aspects of a patient's visit are documented in an organized manner, enhancing the continuity of care and making it easier for other providers to understand the patient's history and treatment plan.