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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.

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).

The Problem or Diagnosis is the first section of the SOAP Note. While learning how to write in the SOAP Note format, you will notice you are using the same information that you used to write in the Patient/Client Management Note format.

SOAP stands for Subjective, Objective, Assessment, and Plan. Each letter refers to one of four sections in the document you will create with your notes.

Differential Diagnosis: This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.

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).

What does SOAP stand for in nursing? SOAP is an acronym used across medical fields to describe a method of charting. It stands for subjective, objective, assessment, and plan.

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A SOAP note consists of four sections including subjective, objective, assessment and plan.

Find the appropriate time to write SOAP notes. Maintain a professional voice. Avoid overly wordy phrasing. Avoid biased overly positive or negative phrasing. Be specific and concise. Avoid overly subjective statement without evidence. Avoid pronoun confusion. Be accurate but nonjudgmental.