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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.

Edit a signed SOAP or Simple Note An encounter cannot be edited or deleted after it has been signed. The act of signing a chart note renders the note a legal document. However, you can add an amendment/addendum to the note.

SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record.

Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress.

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.

DAP notes are somewhat less structured than SOAP or BIRP notes and provide a more narrative account of a client's progress in therapy. They're often used in community mental health settings and are helpful for documenting a client's progress in a more holistic way.

The audience of SOAP notes generally consists of other healthcare providers both within the writer's own field as well in related fields but can also include readers such as those associated with insurance companies and litigation.