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SOAP stands for Subjective, Objective, Assessment, and Plan. Each letter refers to one of four sections in the document you will create with your notes.

Assessment. It can help to think of the assessment section of a SOAP note as the synthesis between the subjective and objective information you have gathered. Using your knowledge of the patient's symptoms and the signs you have identified will lead to a diagnosis or informed treatment plan.

The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections. Summarise the salient points: ?Productive cough (green sputum)? ?Increasing shortness of breath?

Assessment. In this section, the professional combines what they know from both the subjective and objective information. Here, the therapist or doctor identifies the primary problem, along with any contributing factors. They also analyze the interaction between problems, as well as any changes.

The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections. Summarise the salient points: ?Productive cough (green sputum)? ?Increasing shortness of breath?

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Each category is described below: S = Subjective or symptoms and reflects the history and interval history of the condition. The patient's presenting complaints should be described in some detail in the notes of each and every office visit.

In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the reasoning/evidence behind it. This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options.

Assessment: The next section of a SOAP note is assessment. An assessment is the diagnosis or condition the patient has. In some instances, there may be one clear diagnosis.Plan: The last section of a SOAP note is the plan, which refers to how you are going to address the patient's problem.

Subjective. This component is in a detailed, narrative format and describes the patient's self-report of their current status in terms of their current condition/complaint, function, activity level, disability, symptoms, social history, family history, employment status, and environmental history.

SOAP notes include a statement about relevant client behaviors or status (Subjective), observable, quantifiable, and measurable data (Objective), analysis of the information given by the client (Assessment), and an outline of the next course of action (Planning).