SOAP note
Also written as: SOAP — Subjective, Objective, Assessment, Plan
Standardized documentation format used in psychiatric therapy to record clinical encounters systematically.
Full Definition
A SOAP note is a structured documentation method used in psychiatric therapy and other healthcare settings to record patient encounters systematically. The format includes four sections: Subjective (patient's reported symptoms and concerns), Objective (observable behaviors and mental status findings), Assessment (clinical analysis and diagnosis), and Plan (treatment interventions and follow-up). This standardized approach ensures comprehensive documentation, facilitates communication between providers, and meets regulatory requirements for clinical record-keeping.
Usage
Usage note: Acronym always capitalized. Format emphasizes systematic documentation structure.
In Context
- "The therapist documented the session using the standard SOAP note format." — Clinical documentation
- "Training emphasized the importance of complete SOAP notes for continuity of care." — Professional development program