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Differential Diagnosis: This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.

SOAP notes have four main parts, designed to help improve evaluations and standardize documentation: Subjective - What the patient tells you. Objective - What you see. Assessment - What you think is going on. Plan - What you will do about it.

SOAP notes include a statement about relevant client behaviors or status (Subjective), observable, quantifiable, and measurable data (Objective), analysis of the information given by the client (Assessment), and an outline of the next course of action (Planning).

Assessment. This section combines all the information gathered from the subjective and objective sections. It's where you describe what you think is going on with the patient.

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.

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 Problem or Diagnosis is the first section of the SOAP Note. While learning how to write in the SOAP Note format, you will notice you are using the same information that you used to write in the Patient/Client Management Note format.

Nurses and other healthcare providers use the SOAP note as a documentation method to write out notes in the patient's chart. SOAP stands for subjective, objective, assessment, and plan.

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan.S = Subjective or symptoms and reflects the history and interval history of the condition. The patient's presenting complaints should be described in some detail in the notes of each and every office visit.

Most healthcare clinicians including nurses, physical and occupational therapists and doctors use SOAP notes. As a med student, you also need to use a SOAP note format. The purpose of a SOAP note is to have a standard format for organizing patient information.