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SOAP notes. 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.

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.

276e Previous Next 276f SOAP stands for Simple Object Access Protocol. SOAP is an application communication protocol. SOAP is a format for sending and receiving messages. SOAP is platform independent.

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.

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.

It is essential to make the most clinically relevant data in the medical record easier to find and more immediately available. The advantage of a SOAP note is to organize this information such that it is located in easy to find places.

What is the benefit of using SOAP notes? Employees know where to look for information. How should subjective statements by the patient be documented?