What acronym represents the documentation that includes subjective, objective, assessment, and plan of care?

The acronym that represents the documentation including subjective, objective, assessment, and plan of care is known as the SOAP note. Each component serves a specific purpose:

• The subjective section captures the patient's personal report of their symptoms and experiences, providing valuable insight into their condition from their perspective.
• The objective section consists of measurable data and observations collected during the physical examination or diagnostic tests, ensuring a factual basis for the assessment.
• The assessment section synthesizes the information from the subjective and objective findings to establish a clinical judgment regarding the patient's status.
• Lastly, the plan section outlines the proposed interventions, goals, and follow-up strategies tailored to the patient's needs.

This structured format is essential for effective communication among healthcare providers and ensures a comprehensive approach to patient care.

In contrast, other acronyms like PMH note focus specifically on the patient's past medical history, HPI note emphasizes the history of the present illness, and RAP note may pertain to risk assessment protocols without encapsulating the broad scope of information found in a SOAP note.