What does SOAP stand for in medical documentation?

• A. Subjective, Objective, Assessment, Plan
• B. Subjective, Objective, Analysis, Protocol
• C. Subjective, Observational, Assessment, Procedure
• D. Subjective, Objective, Action, Plan

Answer: (A)

In medical documentation, a SOAP note uses four sections to organize information: Subjective, Objective, Assessment, and Plan. This structure helps clinicians capture the patient’s own reports and history (Subjective), the measurable findings from examination and tests (Objective), the clinician’s interpretation and likely diagnoses (Assessment), and the proposed next steps for care (Plan).

Subjective includes what the patient tells you—symptoms, onset, severity, and relevant history. Objective covers what you observe or measure—vital signs, exam findings, and test results. Assessment is where you synthesize the gathered information into a diagnosis or differential diagnoses. Plan outlines the treatment plan, including medications, tests, referrals, and follow-up.

The other options mix terms that aren’t part of the standard SOAP framework, such as Analysis or Protocol, Observational or Procedure, or Action in place of Plan. These don’t align with the established four-component structure, making the first option the best choice.