SOAP Note
Also written as: SOAP — Subjective, Objective, Assessment, Plan
Documentation format organizing clinical information into Subjective, Objective, Assessment, and Plan sections.
Full Definition
SOAP notes provide a structured framework for clinical documentation where Subjective includes patient-reported symptoms, Objective covers observable findings and test results, Assessment contains diagnostic impressions, and Plan outlines treatment interventions. This format ensures comprehensive, organized documentation that meets regulatory requirements and facilitates communication between providers. Mental health SOAP notes often emphasize subjective reports and therapeutic interventions.
Usage
Usage note: Always capitalize SOAP; note is lowercase when following the acronym.
In Context
- "The therapist documented the session using the standard SOAP note format." — Clinical documentation
- "Under the Assessment section of the SOAP note, the clinician noted improved mood stability." — Progress documentation