The Online Resource for Medical Transcription Professionals
Medical record number
The SUBJECTIVE heading lets you know that the doctor is giving an abbreviated history. This heading is used in place of
HISTORY OF PRESENT ILLNESS when a detailed history is not necessary, usually because the detailed history is already in the
patient's chart. Only changes to the original history will be dictated here. The SUBJECTIVE heading will include
information given by the patient about how they are feeling, what brings them to the medical visit, and any other opinions given
by the patient, person accompanying the patient or a caretaker.
Whereas the SUBJECTIVE heading gives the patient's condition from the patient's point of view, the OBJECTIVE heading are findings
from the doctor's point of view. This usually has some of the same information as a PHYSICAL EXAM, and often is formatted
identically. Often the only difference is the brevity of the information. As in the SUBJECTIVE section,
many times only the changes since last visit will be listed, or a brief, overall summary of some of the more major systems
will be listed. This section also would list any pertinent LABORATORY DATA.
The ASSESSMENT portion of the note highlights the diagnosis that is specific to this particular visit. Often a patient
will have several diagnoses; however, in a SOAP note format, brevity rules, which means often doctors will only dictate their assessment
of the patient's reason for visit on that particular day. Another popular use is to briefly list all current diagnoses
listed in their medical record, but only state the PLAN for the immediate ailment for which the patient is being seen.
A PLAN is fairly self-explanatory. This is the section where the doctor will outline the plan of action for the patient.
Again, this usually will only outline the plan for the ailments of the current visit, and if the patient is generally
healthy and just there for a checkup, this might be just a return-to-clinic-in-X-months recommendation. It could
contain treatment information, referrals to other physicians or specialists, or simply highlight a treatment plan that
is already in effect. Occasionally, the doctor will say everything he wants to say about a plan in the ASSESSMENT
section, and leave out the PLAN entirely.
So perhaps you have heard of a SOAP note when learning about a Medical Transcription career. The term "SOAP" simply refers to
the 4 headings in this type of report. Subjective, Objective, Assessment and Plan= SOAP. The basic rule of a SOAP
note is brevity; this is not usually a lengthy history detailing all the facts of the patient's health status. This is
a popular format for checkups, for instance, if a patient comes in with a sore throat, or a followup visit when
a patient comes in for a check on their current status of an existing illness. Of course, some doctors insist on
using this format for everything, which is incorrect, but the client is always right!
In summary, a SOAP format is mostly used for brief updates of a patient's condition. There are exceptions to this
rule, as well as times that doctors will use it inappropriately. Even though a dictation of a SOAP note may
add headings or omit one of the 4 headings, you can still refer to it as a SOAP note if it is a brief note that summarizes the
patient's current condition, and does not act as a HISTORY AND PHYSICAL, DISCHARGE SUMMARY or other type of note with
a different purpose.
Medical Transcription Quick Links:
Visit our Sample Medical Reports
page to see samples of medical transciption reports in SOAP note format, as well as other popular