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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.

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.

All progress notes should include a succinct summary on the following: A client's progress towards goals identified in Individual Support Plans (actions taken, progress made, barriers identified).

The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient's current presentation, such as: Vital signs are often already included in the chart. However, it is an important component of the SOAP note as well. Vital signs and measurements, such as weight.

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

HPI: include symptom dimensions, chronological narrative of patient's complains, information obtained from other sources (always identify source if not the patient). Pertinent past medical history. Pertinent review of systems, for example, Patient has not had any stiffness or loss of motion of other joints.

Plan: The last section of a SOAP note is the plan, which refers to how you are going to address the patient's problem. It may involve ordering additional tests to rule out or confirm a diagnosis. It may also include treatment that is prescribed, such as medication or surgery.