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Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress. SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds.

The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers.

SOAP notes document details from patient visits and let you communicate vital information to other healthcare providers.SOAP notes let you record a patient's initial assessment, diagnosis, and treatment details in a standardized format, which can also be shared with and used by other healthcare providers.

SOAP Note TemplateDocument patient information such as complaint, symptoms and medical history.Take photos of identified problems in performing clinical observations.Conduct an assessment based on the patient information provided on the subjective and objective sections.Create a treatment plan.More items...

SOAP Note TemplateDocument patient information such as complaint, symptoms and medical history.Take photos of identified problems in performing clinical observations.Conduct an assessment based on the patient information provided on the subjective and objective sections.Create a treatment plan.More items...?Dec 9, 2021

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

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below. This is the first heading of the SOAP note. Documentation under this heading comes from the subjective experiences, personal views or feelings of a patient or someone close to them.