SOAP Note
Also written as: SOAP — Subjective, Objective, Assessment, Plan
A structured documentation format using Subjective, Objective, Assessment, and Plan sections to organize patient information.
Full Definition
SOAP notes are the standard documentation format in physical therapy practice, organizing patient information into four distinct sections. The Subjective section captures patient-reported information, Objective records measurable findings, Assessment provides professional clinical judgment, and Plan outlines treatment strategies. This format ensures comprehensive documentation while meeting regulatory requirements. Editors must maintain consistent formatting and ensure each section contains appropriate content types.
Usage
Usage note: Always capitalize as 'SOAP' when referring to the documentation format.
In Context
- "All treatment sessions must be documented using the SOAP note format." — Documentation policy
- "The Assessment section of the SOAP note should reflect clinical reasoning." — Documentation training