Communication and documentation
SOAP
Subjective, Objective, Assessment, Plan
A note format that keeps what the patient reports separate from what the clinician observed, before any interpretation is written down.
What each letter stands for
- 1 Subjective — what the patient reports, in their words.
- 2 Objective — measurable findings and observations.
- 3 Assessment — what those add up to.
- 4 Plan — what happens next.
How it gets tested
The tested distinction is S against O. A pain rating of 7/10 is subjective, because it is reported; a blood pressure reading is objective, because it is measured.
Related terms
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