Evaluation and Management documentation is often captured in SOAP format, which stands for:

SOAP format is a widely accepted method used in medical documentation to create a structured approach for recording patient information during evaluations and management encounters. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan.

1. Subjective: This section captures the patient's personal experience of their symptoms, including their feelings and perceptions regarding their condition. These details are based on what the patient reports during the consultation and lay the groundwork for understanding their clinical scenario.

2. Objective: Here, healthcare professionals document their findings based on observable and measurable data. This can include vital signs, results from physical examinations, laboratory results, and any imaging studies. Objective data provides a factual basis that complements the subjective information provided by the patient.

3. Assessment: This portion includes the clinician's interpretation of the subjective and objective findings. It often encompasses the diagnosis or any clinical impressions stemming from the evaluation. This part synthesizes the data collected to provide a clear picture of the patient's status.

4. Plan: The plan outlines the recommended course of action for managing the patient's condition. It may include treatment options, follow-up appointments, referrals to other healthcare providers, or educational resources given to the patient.

The SOAP format is essential in clinical documentation as it