SOAP note
Also written as: SOAP — Subjective, Objective, Assessment, Plan
Standard documentation format used by occupational therapists following Subjective, Objective, Assessment, Plan structure.
Full Definition
SOAP note is a standardized documentation format widely used in occupational therapy and other healthcare disciplines. It organizes clinical information into four sections: Subjective (client's reported symptoms and concerns), Objective (measurable observations and test results), Assessment (therapist's clinical reasoning and interpretation), and Plan (treatment goals and interventions). This format ensures comprehensive, organized documentation that meets regulatory requirements and facilitates interprofessional communication.
Usage
Usage note: Each section should be clearly labeled in clinical documentation; avoid mixing content between sections.
In Context
- "The occupational therapist documented the session using standard SOAP note format." — Clinical documentation
- "Medicare requires SOAP note documentation to justify skilled occupational therapy services." — Billing compliance guide