What does SOAP stand for in clinical documentation?

• A. Subjective, Objective, Assessment, Plan
• B. Subjective, Objective, Analysis, Plan
• C. Subjective, Operative, Assessment, Plan
• D. Summary, Objective, Assessment, Plan

Answer: (A)

SOAP is a standardized framework for clinical notes: Subjective, Objective, Assessment, Plan. The first part captures the patient’s own report of symptoms, history, and concerns. The second part records measurable, observable information gathered during the exam or from tests—vital signs, exam findings, and results. The third part is where the clinician synthesizes the data into an interpretation or diagnosis, often including a differential if needed. The final part outlines the plan for treatment and follow-up, such as therapies, medications, referrals, and next steps.

Other options don’t fit the established structure: one uses an term that isn’t part of SOAP’s standard categories, another substitutes a nonstandard word for the second component, and another replaces the initial category with a term that doesn’t represent patient-reported information.