SOAP notes (subjective, objective, assessment, plan)

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
July 8th, 2015

SOAP notes (subjective, objective, assessment, plan)

 Each letter in “SOAP” is a specific heading in the notes:

 SOAP is an acronym for “subjective” ( S ) or the patient’s re-response and feeling to treatment, “objective” (O) or the observations of the clinician, “assessment” (A) or diagnosis of the problem, and “procedures accomplished and plans” (P) for subsequent problem resolving activities.

 Soap Format

 S – refers to subjective, the purpose of the patient’s dental visit.  This section also includes the description of symptoms in the patient’s own words including:  pain, what triggers the discomfort, what causes the discomfort to disappear and the length of time these symptoms have been occurring.

 O – refers to objective, unbiased observations.  Included under this heading would be things that can actually be felt, heard, measured, seen, smelled and touched.

 A– refers to assessment, the diagnosis of the patient’s condition.  The diagnosis may be clear or there may be several diagnostic possibilities.

 P – refers to the plan or proposed treatment, and is decided upon by the patient and the provider.  The plan may include radiographs, medications prescribed, surgical procedures, patient referral to specialists and patient follow-up care instructions.

 The Business of Dentistry: Patient Records and Records Management

 

 

References:

SOAP notes (subjective, objective, assessment, plan). (2015, July 8). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/soap-notes-subjective-objective-assessment-plan-27087.html

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