SOAP note
Formal Definition
A structured clinical documentation format divided into four sections: Subjective (patient-reported symptoms and history), Objective (vital signs, exam findings, lab/imaging data), Assessment (diagnosis or differential), and Plan (treatment, workup, follow-up).
How It's Used on the Ward
"Write a SOAP note" or "SOAP format" — the backbone of daily progress notes and outpatient visits.
Example
""Attending to third-year: 'Your daily note is just a list of lab values. Where's the assessment? Where's the plan? Write me a proper SOAP — what does this patient have, and what are we doing about it today?'""
Clinical Context
The SOAP format is taught early and used forever, but the Assessment and Plan are what matter most. The S and O describe; the A and P decide. A note heavy on S and O with a thin A&P is passive documentation — the note should reflect clinical reasoning. In progress notes, the A&P should answer: is the patient better or worse, why, and what's the plan? One problem per numbered item in the plan.