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Objective. While your client is the primary source of subjective data, you're the main source of objective data. This section is where you'll spell out what happened during the session. Include data like the type of interventions you used, the client's reactions, and the results you achieved.

However, all SOAP notes should include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP. A SOAP note should convey information from a session that the writer feels is relevant for other healthcare professionals to provide appropriate treatment.

An example of this is a patient stating he has ?stomach pain,? which is a symptom, documented under the subjective heading. Versus ?abdominal tenderness to palpation,? an objective sign documented under the objective heading.

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?

Objective. While your client is the primary source of subjective data, you're the main source of objective data. This section is where you'll spell out what happened during the session. Include data like the type of interventions you used, the client's reactions, and the results you achieved.

The Objective (O) part of the note is the section where the results of tests and measures performed and the therapist's objective observations of the patient are recorded. Objective data are the measurable or observable pieces of information used to formulate the Plan of Care.

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.

The order in which a medical note is written has been a topic of discussion. While a SOAP note follows the order Subjective, Objective, Assessment, and Plan, it is possible, and often beneficial, to rearrange the order.

Tips for Effective SOAP NotesFind the appropriate time to write SOAP notes.Maintain a professional voice.Avoid overly wordy phrasing.Avoid biased overly positive or negative phrasing.Be specific and concise.Avoid overly subjective statement without evidence.Avoid pronoun confusion.Be accurate but nonjudgmental.

Tips for Effective SOAP NotesFind the appropriate time to write SOAP notes.Maintain a professional voice.Avoid overly wordy phrasing.Avoid biased overly positive or negative phrasing.Be specific and concise.Avoid overly subjective statement without evidence.Avoid pronoun confusion.Be accurate but nonjudgmental.