SOAP note
Also written as: SOAP — Subjective, Objective, Assessment, Plan
A structured documentation format used in psychiatric settings to record patient encounters using Subjective, Objective, Assessment, and Plan sections.
Full Definition
SOAP note is a standardized method of documentation in psychiatric practice that organizes clinical information into four distinct sections: Subjective (patient's reported symptoms and concerns), Objective (observable clinical findings and mental status examination), Assessment (clinical impression and diagnosis), and Plan (treatment interventions and follow-up). This format ensures comprehensive and consistent documentation across different clinicians and settings. In psychiatric contexts, the subjective section often includes detailed patient narratives about mood, thoughts, and behaviors, while the objective section focuses on mental status examination findings.
Usage
Usage note: Always capitalize as SOAP when referring to the documentation format.
In Context
- "The resident's SOAP note failed to adequately document the patient's suicide risk assessment in the plan section." — Clinical documentation review
- "All psychiatric SOAP notes must include a mental status examination in the objective section." — Training manual