SOAP

Clinical information

Clinical information

S - O - A - P

1. SUBJECTIVE — The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by a significant other. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes(Coy, et al, 2006).

2. OBJECTIVE — The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, ...