📁 Charting & SOAP Notes

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5 Terms

1
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What does SOAP stand for in charting?

Subjective, Objective, Assessment, Plan

2
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What is an example of a “subjective” note?

“Patient reports headache and nausea”

3
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What is an example of an “objective” note?

“BP: 132/84, HR: 76 bpm, Temperature: 98.7°F”

4
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What is the “assessment” part of a SOAP note?

The provider’s diagnosis or findings

5
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What is the “plan” part of a SOAP note?

Next steps — treatment, follow-up, labs, referrals