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Subjective What the Patient Tells youTake note of the patient 's complete statement and enclose it in quotes. Recording patient history such as medical history, surgical history, and social history should also be indicated as it can be helpful in determining or narrowing down the possible causes.

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.

Write them down as factually as possible. The Objective phase is concerned only with raw data, not conclusions or diagnoses on your part. Record any measurable data during the client's session, including applicable test scores. Documenting the Objective phase brings up the issue of separating symptoms from signs.

SOAP notes are still around because they work. EHR has changed many things in how medicine is practiced, but it still takes its model after the SOAP notes that were created decades ago. Their simplicity, together with a comprehensive view of a patient's progress are the two characteristics that make them so efficient.

SOAP (subjective, objective, assessment and plan) notes are an integral part of the vocation of massage therapy. Massage therapists rely on SOAP notes to help create long-term plans for client care, and insurance companies insist on them in order to process reimbursement.

An effective SOAP note is a useful reference point in a patient's health record, helping improve patient satisfaction and quality of care.

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.