What does SOAP stand for in clinical documentation?

• A. Subjective, Objective, Assessment, and Plan
• B. Subjective, Objective, Analysis, and Plan
• C. Subjective, Objective, Assessment, and Protocol
• D. Subjective, Observations, Assessment, and Plan

Answer: (A)

Documenting patient encounters uses a four-part format: Subjective, Objective, Assessment, Plan. The patient’s perspective and reported symptoms go in Subjective, capturing what they say and feel. Objective contains measurable data like vital signs, exam findings, and test results. Assessment is the clinician’s synthesis and impression based on both subjective and objective information. Plan outlines the next steps—treatment, medications, follow-up, and any orders or referrals.

This four-part structure is the standard because it clearly separates what the patient reports from what is observed, then shows how the clinician interprets those data and what actions will be taken. Other terms like Observations, Analysis, or Protocol don’t align with these standard labels and would introduce ambiguity about which information belongs in each section.