SOAP NOTES WITH CORRECT DEFINITION OF
TERMS
SOAP Note Definitions: - ✔✔1) Method of documentation used by health care providers to submit plans
in a patient's chart
2) A way to organize and present patient information in order to assess problems and find solutions
3) Identifies all of a patient's problems and ranks each problem in order of importance (How likely it is to
kill them)
4) SOAP format is used to go through every problem
SOAP Format: - ✔✔S: Subjective
O: Objective
A: Assessment
P: Plan
SOAP; Subjective - ✔✔This is what is described BY THE PATIENT in relation to the problems identified
Includes signs/symptoms and other descriptive information related to how the patient is feeling or
acting
Typically includes information about the CC (Chief Complaint):
- Onset
- If it has gotten worse or better since onset
, - Quality (sharp, dull)
- Severity (scale 1-10)
- Aggravating and remitting factors
- Treatment
IS NOT factual and cannot be reliably reproduced
- Not supported by lab values
SOAP; Subjective Information Example - ✔✔"CL is a 48 yo female presenting to the clinic complaining of
a NAGGING DRY COUGH"
"...cough STARTED ABOUT 1 week ago"
SOAP; Objective - ✔✔This is information and observations made by the healthcare provider relevant to
the patient's problem
Includes:
- Lab values
- Test results
- Physical exam results
- Vital signs
This is MEASURABLE, OBSERVABLE, and REPRODUCIBLE
SOAP; Objective Information Example: - ✔✔HTN
BP 138/88, HR 85
TERMS
SOAP Note Definitions: - ✔✔1) Method of documentation used by health care providers to submit plans
in a patient's chart
2) A way to organize and present patient information in order to assess problems and find solutions
3) Identifies all of a patient's problems and ranks each problem in order of importance (How likely it is to
kill them)
4) SOAP format is used to go through every problem
SOAP Format: - ✔✔S: Subjective
O: Objective
A: Assessment
P: Plan
SOAP; Subjective - ✔✔This is what is described BY THE PATIENT in relation to the problems identified
Includes signs/symptoms and other descriptive information related to how the patient is feeling or
acting
Typically includes information about the CC (Chief Complaint):
- Onset
- If it has gotten worse or better since onset
, - Quality (sharp, dull)
- Severity (scale 1-10)
- Aggravating and remitting factors
- Treatment
IS NOT factual and cannot be reliably reproduced
- Not supported by lab values
SOAP; Subjective Information Example - ✔✔"CL is a 48 yo female presenting to the clinic complaining of
a NAGGING DRY COUGH"
"...cough STARTED ABOUT 1 week ago"
SOAP; Objective - ✔✔This is information and observations made by the healthcare provider relevant to
the patient's problem
Includes:
- Lab values
- Test results
- Physical exam results
- Vital signs
This is MEASURABLE, OBSERVABLE, and REPRODUCIBLE
SOAP; Objective Information Example: - ✔✔HTN
BP 138/88, HR 85
