What Is a SOAP Assessment?
A SOAP assessment is a structured method that healthcare professionals use to document patient encounters. It organizes medical records into four clear sections:
- Subjective – The patient’s perspective, including symptoms, health history, and concerns.
- Objective – Observable and measurable findings such as vital signs, physical exam results, and lab tests.
- Assessment – The provider’s professional judgment, including diagnosis or differential diagnosis.
- Plan – Next steps, such as treatment options, follow-up appointments, or referrals.
This approach ensures consistency in healthcare documentation across clinics, hospitals, and telehealth platforms.
Why SOAP Notes Matter in Patient Care
SOAP assessments are not just for record-keeping - they improve patient care by:
- Creating clear communication between doctors, nurses, and specialists.
- Supporting accurate diagnoses and treatment plans.
- Providing a legal and professional record of the patient encounter.
- Ensuring continuity of care if you move between providers.
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