Which components make up the SOAP method of documentation?

The SOAP method of documentation is a widely used framework for organizing and structuring information in clinical settings, particularly in medical records. The correct components are Subjective, Objective, Assessment, and Plan.

The "Subjective" part includes the patient's perspectives, feelings, and experiences, which are often gathered through dialogue during the patient visit. This section captures the personal context of the patient's condition.

The "Objective" component consists of measurable, observable data collected during an examination or through diagnostics, such as vital signs, lab results, and physical findings. This provides a clear picture of the patient's physical state that can be objectively verified.

The "Assessment" section involves the clinician's interpretation of the subjective and objective information, leading to a diagnosis or a statement about the patient's condition. This step is essential, as it reflects the clinical reasoning process.

Finally, the "Plan" details the next steps in managing the patient's care, which may include treatments, referrals, further testing, or follow-up appointments. This outlines a clear strategy moving forward for both the clinician and the patient.

Other options do not accurately represent the SOAP framework components and thus diverge from the established terminology used in clinical documentation. They either introduce unrelated terms or mix components that do not align with the accepted