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The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note.[1][2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing.[3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.[1]
The SOAP note originated from the problem-oriented medical record (POMR), developed nearly 50 years ago by Lawrence Weed, MD.[1][4] It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way.[4] Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress.[1]
SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds.[2] Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR.[2] Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians.[5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various members of healthcare professions.[2] Many healthcare providers, ranging from physicians to behavioral healthcare professionals to veterinarians, use the SOAP note format for their patient's initial visit and to monitor progress during follow-up care.[4][6][7]
^ abcd"Understanding SOAP format for Clinical Rounds". Gap Medics US change. 2015-01-02. Archived from the original on 2020-07-22. Retrieved 2019-08-31.
^"Ideas and Examples for Improving Workflow". AAP.org. Retrieved 2019-08-31.
^ abcJacobs, Lee (Summer 2009). "Interview with Lawrence Weed, MD: The father of the problem-oriented medical record looks ahead". The Permanente Journal. 13 (3). Kaiser Permanente: 84–89. doi:10.7812/tpp/09-068. PMC 2911807. PMID 20740095.
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