What is the acronym soap in medical terms?

September 22, 2025 •

4 min read

First developed by Dr. Lawrence Weed in the 1960s, the SOAP note became a standardized format for medical record-keeping worldwide. Understanding what is the acronym SOAP in medical terms is crucial for anyone in healthcare, as it is a universal method for documenting patient encounters consistently and clearly.

Quick Summary

The acronym SOAP in medical terms stands for Subjective, Objective, Assessment, and Plan. This structured note-taking format helps healthcare professionals organize and document patient information efficiently for better communication and care continuity.

Key Points

Definition: The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, a standardized method for medical record-keeping.
Origin: Developed by Dr. Lawrence Weed in the 1960s as part of the Problem-Oriented Medical Record (POMR) system.
Purpose: It provides a structured framework for healthcare professionals to document patient encounters clearly and efficiently.
Sections: The Subjective section captures the patient's perspective, the Objective section lists measurable findings, the Assessment is the clinical interpretation, and the Plan is the treatment strategy.
Versatility: Used across many healthcare disciplines, including medicine, nursing, physical therapy, and mental health.
Evolution: While technology has changed how notes are entered, the core principles of the SOAP format remain relevant today.

The Origin and Purpose of SOAP Notes

The SOAP note is a cornerstone of clinical documentation, providing a logical, problem-oriented framework for healthcare professionals. Its development was a revolutionary step away from disorganized, source-oriented medical records. Created by Dr. Lawrence Weed, it was part of a larger concept called the Problem-Oriented Medical Record (POMR), which prioritized patient problems rather than chronological notes. This system helps clinicians in multiple fields, from medicine and nursing to physical therapy and mental health, to clearly and accurately communicate patient information.

The "Problem-Oriented Medical Record"

Before Dr. Weed's innovation, medical records were often a collection of disparate notes from different providers, making it difficult to get a complete picture of a patient's health. The POMR system, with the SOAP note at its core, changed this by focusing on specific patient problems. This allows for a more integrated, comprehensive approach to patient care, ensuring that all providers on a care team have a clear understanding of the patient's condition and treatment plan.

Deciphering the SOAP Acronym: The Four Sections

The acronym SOAP breaks down into four key components, each representing a crucial part of the patient's record.

Subjective (S): The Patient's Story

This section captures the patient's personal experience. It includes information that cannot be measured or observed by the provider but is reported by the patient or a family member. It is often written in the patient's own words to accurately reflect their chief complaint and history of present illness. Examples include:

Chief Complaint (CC): The primary reason for the visit, such as "headache" or "knee pain."
History of Present Illness (HPI): A detailed description of the symptoms, including onset, location, duration, and severity.
Review of Systems (ROS): Any other relevant symptoms the patient reports, organized by body system.

Objective (O): The Measurable Data

Unlike the subjective section, this part is based on factual, measurable data collected by the healthcare provider. It should be free of interpretation and opinion. This section provides the foundation for the assessment and plan.

Vital Signs: Blood pressure, heart rate, temperature, respiratory rate.
Physical Examination: Findings from the physical exam, such as a wound's appearance or range of motion.
Laboratory Results: Measurable data from blood tests, urinalysis, etc.
Imaging Results: Findings from X-rays, MRIs, or other scans.

Assessment (A): The Clinical Interpretation

In this section, the healthcare provider synthesizes the subjective and objective information to form a clinical judgment. The assessment includes a diagnosis or a list of differential diagnoses, explaining the clinical reasoning behind the conclusion. It connects the data from the first two sections to the most likely cause of the patient's problem.

Plan (P): The Path Forward

This final section outlines the course of action. It details the treatment strategy, including any medications, follow-up appointments, or referrals. It is the roadmap for how the patient's health problem will be managed and resolved.

Example: Documenting a Knee Injury

Let's consider a patient presenting with knee pain. A SOAP note might include:

S: "Patient reports a 'sharp, shooting pain' in their right knee that started this morning after running."
O: "Right knee appears swollen. Tenderness to palpation on the medial aspect. Full range of motion achieved with pain."
A: "Probable meniscus tear based on reported mechanism of injury and physical exam findings. Differential diagnosis includes ligament sprain."
P: "Prescribe NSAID for pain. Order MRI of right knee. Refer to orthopedics. Follow-up in 1 week or sooner if pain worsens."

Advantages and Limitations of the SOAP Format

The SOAP note's structured approach offers several benefits, but it also has its limitations. Understanding both sides is important for appreciating its role in modern healthcare.


Aspect	Advantages	Limitations
Clarity	Standardized format ensures notes are organized and easy for other providers to follow.	Can lead to an overly rigid, templated approach that misses crucial nuance.
Communication	Facilitates efficient communication between different specialists and across various EHR systems.	Documentation can become too focused on the four sections, potentially overlooking other important details.
Completeness	Serves as a cognitive aid, ensuring no critical components of the patient encounter are missed.	Might separate the patient's story from the physician's interpretation, rather than presenting a holistic narrative.
Legal & Billing	Provides a thorough legal record and is often used for insurance and billing purposes.	In a fast-paced environment, can sometimes encourage a 'checklist' mentality rather than comprehensive documentation.

Beyond the Basics: Evolving Documentation Practices

While the SOAP note is a valuable tool, healthcare has continued to evolve. The advent of electronic health records (EHRs) has made documentation faster but also introduced new challenges related to data entry and information retrieval. Some practices now use a variation of the SOAP note, such as the APSO (Assessment, Plan, Subjective, Objective) format, which prioritizes the most actionable information at the top. The core principles, however, remain centered on organizing clinical information logically and comprehensively.

For additional detail on the structure and use of SOAP notes, a comprehensive overview can be found on the National Center for Biotechnology Information bookshelf, which provides in-depth medical documentation resources.

Conclusion: The Enduring Legacy of the SOAP Note

Even with the rise of new technologies and different documentation styles, the SOAP note's influence is undeniable. It provides a foundational framework for systematic clinical reasoning, guiding providers to move from the patient's reported symptoms to a diagnosis and a clear treatment plan. By understanding what is the acronym SOAP in medical terms, healthcare professionals and students alike can master a critical skill for effective communication, better patient outcomes, and robust medical record-keeping.

Frequently Asked Questions

SOAP notes are widely used across the healthcare spectrum by physicians, nurses, physician assistants, physical therapists, chiropractors, and mental health professionals to document patient visits and track progress.

They are important because they ensure a consistent, clear, and logical flow of information. This standardization improves communication among healthcare providers, supports clinical decision-making, and creates a robust legal record of care provided.

Yes, while originating in medicine, the SOAP note format is adaptable and used in various fields that require structured client or patient record-keeping. Examples include veterinary medicine, counseling, and occupational therapy.

The Subjective section includes the patient's personal account of their condition. This covers the chief complaint, the history of present illness (e.g., pain, fatigue), and the review of systems, all as reported by the patient.

The Objective section contains factual, measurable data, such as vital signs and lab results. The Assessment section is the provider's professional interpretation and synthesis of both the Subjective and Objective data to arrive at a diagnosis.

While SOAP is dominant, other documentation formats exist. The APSO (Assessment, Plan, Subjective, Objective) format reorders the sections to prioritize the action plan, and narrative notes provide a less structured, story-like account of the patient encounter.

With the rise of Electronic Health Records (EHRs), SOAP notes have moved from paper to digital templates. Many EHR systems now use automated fields and dropdown menus to streamline the process, while AI can even assist in drafting notes from clinical conversations.