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What does "SOAP" stand for in clinical documentation?

Subjective, Objective, Assessment, and Plan

The term "SOAP" stands for Subjective, Objective, Assessment, and Plan, and it represents a structured method for documenting patient interactions in a clinical setting. This format aids healthcare providers in organizing patient information effectively, ensuring that all relevant aspects of care are covered systematically.

The "Subjective" component includes information reported by the patient, such as their symptoms, feelings, and concerns, reflecting their personal experience of the problem. The "Objective" section captures measurable or observable data, such as vital signs, physical examination findings, and laboratory results. Following that, the "Assessment" involves the healthcare provider's clinical judgment, synthesizing the subjective and objective data to determine a diagnosis or evaluation of the patient's condition. Finally, the "Plan" outlines the proposed course of action for the patient's treatment, including medications, further tests, or referrals.

This structured approach not only facilitates clear communication among healthcare providers but also enhances continuity of care, making it essential in clinical documentation practices.

Get further explanation with Examzify DeepDiveBeta

Systematic, Objective, Assessment, and Plan

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