What is SOAP Note format?
SOAP is an acronym that stands for subjective, objective, assessment, and plan. The elements of a SOAP note are:
Subjective (S): Focused on the client's information regarding their experience and perceptions of symptoms, needs, and progress toward treatment goals.
Objective (O): Includes observable, objective data ("facts") regarding the client, like elements of a mental status exam or other screening tools, historical information, medications prescribed, x-rays results, or vital signs.
Assessment (A): Includes the clinician's assessment of the available subjective and objective information. The assessment summarizes the client's status and progress toward treatment plan goals.
Plan (P): Records the actions to be taken due to the clinician's assessment of the member's current status, such as assessments, follow‐up activities, referrals, and changes in the treatment.