What does SOAP stand for in clinical documentation?

• A. Subjective, Assessment, Objective, Plan
• B. Subjective, Objective, Plan, Assessment
• C. Subjective, Objective, Assessment, Plan
• D. Objective, Subjective, Assessment, Plan

Answer: (C)

SOAP notes organize clinical documentation into four parts: Subjective, Objective, Assessment, Plan. The Subjective portion captures the patient’s own words—the chief complaint, symptoms, history, and any information the patient reports that cannot be measured directly. The Objective portion then records what you can observe or measure: physical examination findings, vital signs, test results, imaging, and other measurable data. The Assessment is your clinical interpretation based on the information gathered—this includes the working diagnosis and any differential diagnoses along with reasoning. Finally, the Plan outlines concrete next steps: treatments or medications, orders for tests or referrals, patient education, and scheduling follow-up.

The order matters because it mirrors the flow from the patient’s perspective to the clinician’s findings, then to your diagnostic thinking, and finally to actionable steps. This structure makes it easier to track what the patient reports, what is observed, how you arrived at conclusions, and what will be done next.