what is the soap format in a medical record
SOAP note The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing. The SOAP note originated from the Problem Oriented Medical Record (POMR), developed by Lawrence Weed, MD.[1] It was initially developed for physicians, who at the time, were the only health care providers allowed to write in a medical record. Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patientâ€™s progress. SOAP notes are now commonly found in electronic medical records (EMR) and are used by providers of various backgrounds. Prehospital care providers such as EMTs may use the same format to communicate patient information to emergency department clinicians. Physicians, physician assistants, nurse practitioners, pharmacists, podiatrists, chiropractors, acupuncturists, occupational therapists, physical therapists, school psychologists, speech-language pathologists, certified athletic trainers (ATC), sports therapists, occupational therapists, among other providers use this format for the patient's initial visit and to monitor progress during follow-up care.