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Book

SOAP Notes

Vivek Podder  1 , Valerie Lew  2 , Sassan Ghassemzadeh  3
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
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Book

SOAP Notes

Vivek Podder et al.
Free Books & Documents

Excerpt

The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.

This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning. The SOAP note helps guide healthcare workers use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record.

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Conflict of interest statement

Disclosure: Vivek Podder declares no relevant financial relationships with ineligible companies.

Disclosure: Valerie Lew declares no relevant financial relationships with ineligible companies.

Disclosure: Sassan Ghassemzadeh declares no relevant financial relationships with ineligible companies.

References

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