In medical documentation, what does SOAP stand for?

The term SOAP in medical documentation is an acronym that stands for Subjective, Objective, Assessment, and Plan. This structured method is widely used to ensure that all pertinent information is captured in a clear and organized way during patient evaluations.

In the SOAP format:

• "Subjective" refers to the information reported by the patient, including their symptoms and feelings, which provides insight into their condition from their perspective.
• "Objective" involves the clinician's findings, such as vital signs, physical examination results, and laboratory or imaging data. This section offers measurable and observable facts about the patient's condition.
• "Assessment" is where the healthcare provider evaluates the collected subjective and objective information to form a diagnosis or consider potential issues that may need addressing.
• "Plan" outlines the proposed next steps for treatment, which can include further testing, medication recommendations, referrals, or patient education for managing their condition.

This systematic approach enhances communication among healthcare providers and ensures that all aspects of a patient's condition and care plan are documented effectively. The other options do not accurately reflect the commonly accepted usage of the SOAP format in medical documentation.