What does a SOAP note include?

A SOAP note is a widely used method for documenting patient information in the field of healthcare, particularly in athletic training and physical therapy. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Each component serves a specific purpose in the documentation process.

• The "Subjective" section includes information provided by the patient or athlete regarding their symptoms, feelings, and concerns. This allows the clinician to understand the patient's perspective and how the issue is affecting them personally.

• The "Objective" section contains observable and measurable data collected during the examination. This may include vital signs, results from diagnostic tests, physical exam findings, and other quantifiable information that contributes to a comprehensive understanding of the patient's condition.

• The "Assessment" portion synthesizes the subjective and objective data to provide an overall judgment about the patient's condition. It is where the clinician offers their professional opinion on the diagnosis or the effectiveness of the ongoing treatment.

• Finally, the "Plan" section outlines the intended course of action, including any interventions, treatments, referrals, or follow-up appointments. It establishes clear steps to manage the patient’s care moving forward.

This structured approach not only enhances communication among healthcare providers but also facilitates continuity of care for the patient. The other options do not