What does SOAP stand for in medical documentation?

The term SOAP in medical documentation is an acronym that stands for Subjective, Objective, Assessment, and Plan. This structured method is widely used in clinical settings to organize patient information in a clear and concise manner.

The "Subjective" component includes information that the patient reports about their condition, such as symptoms, feelings, or any relevant history. This portion reflects the patient’s perspective and concerns.

The "Objective" section documents measurable or observable data gathered during the examination, which may include vital signs, lab results, and physical findings. This information is crucial for assessing the patient's health from a medical standpoint.

The "Assessment" part involves the healthcare provider's interpretation of the subjective and objective data, leading to a diagnosis or list of potential diagnoses. This is essential for formulating an understanding of the patient's condition.

Finally, the "Plan" outlines the proposed course of action, including further tests, treatments, or referrals. This structured approach enhances communication among healthcare providers and ensures a comprehensive understanding of patient care.

Each of these elements contributes to a complete picture of the patient's health and facilitates better decision-making and continuity of care. This is why the first choice is the correct answer.