SOAP note
Also written as: SOAP — Subjective, Objective, Assessment, Plan
A structured clinical documentation format comprising four sections—Subjective, Objective, Assessment, and Plan—widely used in rehabilitation therapy records.
Full Definition
The SOAP note format organizes clinical information into: Subjective (patient-reported symptoms and history), Objective (measurable findings from examination or observation), Assessment (the clinician's clinical impression or diagnosis), and Plan (proposed interventions, referrals, or follow-up). It is the dominant progress-note format across physical therapy, occupational therapy, and speech-language pathology in rehabilitation settings. Editors copyediting therapy notes must ensure each section is correctly labeled, that patient-reported information is placed under S rather than O, and that measurable data (e.g., range-of-motion values, grip strength) appear under O. The abbreviation SOAP is always written in full capitals.
Usage
Usage note: Always capitalise all four letters. The 'A' stands for Assessment, not 'Analysis'; verify this is consistent in the source document.
In Context
- "The physiotherapist's SOAP note documented a 10-degree improvement in knee flexion ROM under the Objective heading." — Outpatient rehabilitation progress note
- "The editor moved the patient's pain-rating comment from the Objective to the Subjective section of the SOAP note." — Clinical documentation copyediting task