SOAP Note
Also written as: SOAP — Subjective, Objective, Assessment, Plan
A structured clinical documentation format organizing patient encounter information under four headings: Subjective, Objective, Assessment, and Plan.
Full Definition
A SOAP note is a widely used clinical documentation framework in which patient encounter information is recorded under four sections: Subjective (patient-reported symptoms and history), Objective (clinical findings, measurements, and observations), Assessment (diagnosis or clinical impression), and Plan (proposed treatment or next steps). In dental practice, SOAP notes are used for documenting emergency visits, specialist consultations, and medically complex patient appointments. Editors reviewing dental clinical notes should ensure that the four-section structure is preserved and clearly delineated, that the headings are consistently formatted, and that clinical content is not inadvertently moved between sections. SOAP is always rendered in all capitals as an acronym.
Usage
Usage note: Always capitalise all four letters: SOAP. Do not reorder or merge sections when editing for brevity.
In Context
- "The emergency dental visit was documented using a SOAP note, with the patient's chief complaint recorded in the Subjective section." — Clinical patient record
- "When editing SOAP notes, do not merge the Objective and Assessment sections, even if the content appears to overlap." — Editorial style guide