SOAP note

The SOAP note is short for subjective, objective, assessment, and plan. It is a short method employed by doctors to write out patient encounter notes.

The subjective describes the patient's current condition in narrative form, usually beginning with the patient's age and gender. It will include all pertinent and negative symptoms.

The objective includes vital signs , findings from physical examinations, and results from laboratory tests.

The assessment is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely.

The plan is what the doctor will do to treat the patient's concerns. This should address each item of the differential diagnosis.