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Introduction. 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.

Objective means that it is measurable and observable. In this section, you will report anything you and the client did; scores for screenings, evaluations, and assessments; and anything you observed. The O section is for facts and data. The O section is NOT the place for opinions, connections, interpretations, etc.

To edit a SOAP Note, navigate to your: Personal Profile. Select SOAP Notes. Type in Search Clients to find and select a Client to open their history. Locate and select the SOAP Note to open the current version. Select Edit to activate the fields and tools. Make changes as needed.

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.

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.

Assessment. It can help to think of the assessment section of a SOAP note as the synthesis between the subjective and objective information you have gathered. Using your knowledge of the patient's symptoms and the signs you have identified will lead to a diagnosis or informed treatment plan.

Subjective - What the patient says about the problem / intervention. Objective - The therapists objective observations and treatment interventions. (e.g. ROM, Outcome Measures) Assessment - The therapists analysis of the various components of the assessment.

However, all SOAP notes should include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP.

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.

Writing a SOAP NoteSelf-report of the patient.Details of the specific intervention provided.Equipment used.Changes in patient status.Complications or adverse reactions.Factors that change the intervention.Progression towards stated goals.Communication with other providers of care, the patient and their family.