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SOAP Notes
Ch#1&2
9
Other
Graduate
11/07/2007
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Term
"SOAP" stands for:
 Definition

Subjective - information gathered from the patient and associates

 

Objective - information obtained from a therapist's tests/measures

 

Assessment - evaluation, diagnosis, and prognosis

 

Plan - plan of care
Term
Subjective OAP
 Definition
Term
S Objective AP
 Definition
Term
SO Assessment P
 Definition
Term
SOA Plan
 Definition
Term
Components of the Patient/Client Management Note
 Definition

History - Subjective/Objective

 

Systems Review - Objective

 

Tests and Measures - Objective

 

Diagnosis - Assessment

 

Prognosis - Assessment

 

Plan of Care - Plan
Term
SOAP Note - Accuracy
 Definition
keep it correct and objective
Term
SOAP Note - Brevity
 Definition
short, concise, succinct
Term
SOAP Note - Clarity
 Definition
legible handwriting, maintain consistent tenses
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