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Subjective What the Patient Tells you. This section refers to information verbally expressed by the patient. Objective What You See. This section consists of observations made by the clinician. Assessment What You Think is Going on. Plan What You Will Do About It.

O: Objective This section is where you document measurable outcomes about your client's performance, including test scores, percentages for any goals worked on, and other quantitative information.

Today, the SOAP note an acronym for Subjective, Objective, Assessment and Plan is the most common method of documentation used by providers to input notes into patients' medical records. They allow providers to record and share information in a universal, systematic and easy to read format.

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below. This is the first heading of the SOAP note. Documentation under this heading comes from the subjective experiences, personal views or feelings of a patient or someone close to them.

Components. The four components of a SOAP note are Subjective, Objective, Assessment, and Plan.

This section documents the synthesis of subjective and objective evidence to arrive at a diagnosis. This is the assessment of the patient's status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following.

SOAP notes are a type of progress note. The SOAP format includes four elements that match each letter in the acronym Subjective, Objective, Assessment and Plan. These four sections remind counselors of the information they must collect when enabling appropriate treatment.