The SOAP Note
The SOAP (Subjective, Objective, Assessment, Plan) format has been universally adopted by the medical community as the standard format for documentation. Conveniently, the structure is representative of how the diagnostic and treatment process is typically done. More than that, having a conventional method of documentation allows for easier communication between medical providers. There are several frequently used derivations of this format, but the fundamental elements of “Subjective, Objective, Assessment and Plan” are usually present.