What does the acronym SOAP stand for in patient assessment?

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, and it is a widely used framework in patient assessment and documentation in the medical field.

In this framework, the "Subjective" component includes information shared by the patient about their symptoms, feelings, and personal perspectives regarding their condition. This is crucial because it helps healthcare providers understand the patient’s experience from their point of view.

The "Objective" part includes measurable and observable data that the clinician gathers during the examination. This can involve vital signs, physical examination findings, and results from diagnostic tests, providing a factual basis for further decision-making.

The "Assessment" section is where healthcare providers synthesize the subjective and objective information to come to a diagnosis or a summary of the patient's condition. This is an essential step that links what the patient reports with the clinical findings.

Finally, the "Plan" outlines the treatment strategy going forward, which may include medication, referrals, further tests, or other therapeutic interventions based on the previous components.

This structured approach ensures thorough communication, continuity of care, and it aids in tracking the patient's progress over time. Understanding the components of SOAP is vital for rehabilitation technicians and other healthcare professionals to document patient interactions accurately and effectively.