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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.

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.

They are entered in the patients medical record by healthcare professionals to communicate information to other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning process. SOAP is an acronym for: Subjective - What the patient says about the problem / intervention.

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

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).

Subjective What the Patient Tells you. This section refers to information verbally expressed by the patient. Objective What You See. Assessment What You Think is Going on. Plan What You Will Do About It.

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan.