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 patients current condition in a story manner. Usually it is started with the patient's age and gender. It will include all pertinent symptoms and negative symptoms.

The objective includes vital signs, physical exam findings, and lab results.

The assessment is a quick summary of the patient with main symptoms/diagnosis with a list of differential diagnosis 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.