Patient SOAP Note Charting Procedures
SOAP stands for Subjective, Objective, Assessment, and Plan, and it’s a standard method used by healthcare providers to document patient encounters.
S = Subjective
Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
O = Objective
Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
A = Assessment
The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
P = Plan
Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
Looking for Help With Your SOAP Note Assignment?
At Crafted Papers, we offer expertly written custom SOAP notes tailored to your patient case scenarios, clinical guidelines, and school requirements. Whether you need a sample to learn from or a fully customized chart, our experienced nursing writers are here to help.
👉 Need a SOAP Note Sample or a Custom Paper?