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What Is a S.O.A.P. Note?

User DTRT
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Final answer:

A S.O.A.P. note is a method of organizing patient information in a structured format used by healthcare professionals. It includes subjective, objective, assessment, and plan sections.

Step-by-step explanation:

A S.O.A.P. note is an acronym used in medical documentation to stand for Subjective, Objective, Assessment, and Plan. It is a method of organizing patient information in a structured format, commonly used by healthcare professionals such as doctors, nurses, and therapists.

The Subjective section of the S.O.A.P. note includes the patient's reported symptoms, their medical history, and any other relevant information provided by the patient.

The Objective section contains measurable observations and findings obtained during the physical examination, diagnostic tests, and laboratory results.

The Assessment section is where the healthcare professional provides their clinical impression or diagnosis based on the subjective and objective information.

The Plan section outlines the recommended treatment options, medications, tests, or follow-up actions for the patient.

User Zumafra
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