<P> The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note . Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing . The SOAP note originated from the Problem Oriented Medical Record (POMR), developed by Lawrence Weed, MD . It was initially developed for physicians, who at the time, were the only health care providers allowed to write in a medical record . Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress . SOAP notes are now commonly found in electronic medical records (EMR) and are used by providers of various backgrounds . Prehospital care providers such as EMTs may use the same format to communicate patient information to emergency department clinicians . Physicians, physician assistants, nurse practitioners, pharmacists, podiatrists, chiropractors, acupuncturists, occupational therapists, physical therapists, school psychologists, speech - language pathologists, certified athletic trainers (ATC), sports therapists, occupational therapists, among other providers use this format for the patient's initial visit and to monitor progress during follow - up care . </P> <P> The four components of a SOAP note are Subjective, Objective, Assessment, and Plan . The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status . </P> <P> Initially the patient's Chief Complaint, or CC . This is a very brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization . </P> <P> If this is the first time a physician is seeing a patient, the physician will take a History of Present Illness, or HPI . This describes the patient's current condition in narrative form . The history or state of experienced symptoms are recorded in the patient's own words . All information pertaining to subjective information is communicated to the healthcare provider by the patient or his / her representative . It will include all pertinent and negative symptoms under review of body systems . Pertinent medical history, surgical history, family history, and social history, along with current medications, smoking status, drug / alcohol / caffeine use, level of physical activity and allergies, are also recorded . A SAMPLE history is one method of obtaining this information from a patient . </P>

Where do labs go in a soap note