What does the term "SOAP" refer to in medical records?

The term "SOAP" in medical records refers specifically to a structured method of documentation used to organize patient information and facilitate effective communication among healthcare providers. The elements of SOAP are:

• Subjective: This component includes the patient's reported symptoms and concerns, capturing their personal experience of their condition. It often contains details about their medical history and the reason for their visit.

• Objective: This part encompasses observable and measurable data collected during the examination, such as vital signs, physical examination findings, laboratory results, and imaging studies.

• Assessment: In this section, the healthcare provider synthesizes the subjective and objective information to arrive at a diagnosis or problem list. This interpretation is critical for guiding further treatment.

• Plan: The final element outlines the proposed management strategies, treatments, tests, and follow-up care to address the identified issues.

Each component builds upon the previous one to provide a comprehensive understanding of the patient's situation, making the SOAP framework a valuable tool for healthcare practitioners.