Since doctors have to keep track of so much vital information for so many different patients, good documentation is key. Documentation prevents patient injury and lawsuits against doctors. It provides health care professionals with a means to communicate with one another on important health information for their patients. One method of keeping good documentation is to use the "SOAP" format. "S" for "subjective," "O" for "objective," "A" for "assessment," and "P" for "plan."
Describe the problem in the patient's own words (SUBJECTIVE). Describe the patient's complaint and include any other associated complaints. If this is your first time seeing a patient, a thorough medical history and physical assessment may be appropriate.
Record your OBJECTIVE data. This can include vital signs, lab results, or discoveries found during the physical assessment.
Make an ASSESSMENT of the medical problem. This is the medical diagnosis that you formulate after considering all of the information you have about the patient's problem.
PLAN your interventions. This is what you intend to do about the medical problem, which could include no treatment, watchful waiting, further testing, medications, therapies or surgeries.