SOAP

One of a standard style of charting (documenting) procedures for progress notes in patient’s medical records; the acronym means subjective, objective, assessment, plan. Subjective = statements of symptoms and chief complaints (CC) in the patient’s own words, which is the reason for the encounter. Objective = facts and findings from the physical examination, x-rays, laboratory, and other diagnostic tests. Assessment = evaluation of subjective and objective findings, which is medical decision-making by putting all the facts together to obtain a diagnosis. Plan of treatment = documentation of a strategy for care to be put into action and list of recommendations, instructions, further testing, and medication. Also see CHEDDAR .