The essential SOAP note in an EHR age

Nurse Pract. 2016 Feb 18;41(2):29-36. doi: 10.1097/01.NPR.0000476377.35114.d7.

Abstract

This article reviews the traditional Subjective, Objective, Assessment, and Plan (SOAP) note documentation format. The information in the SOAP note is useful to both providers and students for history taking and physical exam, and highlights the importance of including critical documentation details with or without an electronic health record.

Publication types

  • Review

MeSH terms

  • Documentation / methods*
  • Electronic Health Records*
  • Humans
  • Medical History Taking
  • Nursing Records*
  • Physical Examination / nursing