SOAP

S

Subjective

O

Objective

A

Assessment

P

Plan

Subjective

The problem in the patient's own words, the duration of the problem, the quality of the problem, any exacerbating or reliving factors.

Objective

Objective data comprises the patient's physical exam, any lab findings, and imaging studies

Assessment

Upon gathering all of the information, the health care provider formulates a logical analysis. An assessment can be a diagnosis, an identification of a problem, or a list of possibilities for the diagnosis, which is known as a differential diagnosis

Plan

The provider formulates a plan, or course of action, consistent with the assessment. This plan could be a treatment with medicine or a procedure or it could also consist of collecting further data to help arrive at a more accurate diagnosis