What does SOAP charting stand for?

SOAP charting is a structured method utilized in clinical documentation that stands for Subjective, Objective, Assessment, and Plan. This framework is designed to organize patient information effectively, ensuring that healthcare providers can communicate clearly and efficiently about the patient's condition and care.

The "Subjective" section captures the patient’s personal experiences, symptoms, and feelings, allowing their perspective to inform the care provider's understanding of the situation. The "Objective" section includes measurable data, such as vital signs, laboratory results, and physical examination findings, providing a factual basis for the clinician's assessment.

Following this, the "Assessment" component presents the clinician’s interpretation of the subjective and objective data, identifying the patient's diagnosis or response to treatment. Finally, the "Plan" outlines the proposed steps in managing the patient's care, including interventions, further tests, and follow-up appointments.

This systematic approach to documentation not only enhances the clarity and organization of patient records but also facilitates better communication among healthcare team members. It supports comprehensive patient care by ensuring that all relevant information is considered and addressed.