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The O: The OBJECTIVE section: A few examples of data included in the objective section: The intensity, duration, location and settings of various modalities. The distance, device, weight bearing status, deviations, compensations and level of assistance for gait (or transfer) training.

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.

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).

Components. The four components of a SOAP note are Subjective, Objective, Assessment, and Plan.

HPI: include symptom dimensions, chronological narrative of patient's complains, information obtained from other sources (always identify source if not the patient). Pertinent past medical history. Pertinent review of systems, for example, Patient has not had any stiffness or loss of motion of other joints.

SOAP notes are a type of progress note. The SOAP format includes four elements that match each letter in the acronym Subjective, Objective, Assessment and Plan. These four sections remind counselors of the information they must collect when enabling appropriate treatment.

Transfer the Vital Signs to the SOAP NoteEnter Vitals. Enter the patients vital signs. Vitals that are required for Meaningful use include:Transfer Vitals to the SOAP note. With a new encounter created, click the Transfer Vitals button to transfer the patients vitals signs into the SOAP Note Objective field.