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The objective section of a SOAP Note is where you'll document any pertinent observable and measurable data concerning your patient. Physicians use this field to record vital signs, physical exam findings, or diagnostic test results.

The assessment section refers to the interpretations or conclusions drawn from the subjective and objective findings.

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 completing SOAP notes: Consider how the patient is represented: avoid using words like ?good? or ?bad? or any other words that suggest moral judgments. Avoid using tentative language such as ?may? or ?seems? Avoid using absolutes such as ?always? and ?never? Write legibly.

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 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 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.