The progress (SOAP) clinical note

The SOAP note, as stated previously, is typically done on a daily basis for patients admitted to a hospital and includes one section for every letter in its acronym: subjective, objective, assessment, and plan (SOAP). The subjective section focuses on any new complaints the patient is having, or had, on the previous night. The objective section includes the daily and focused physical examination and lab, imaging, and test results from the previous day. The assessment and plan are similar to those of the H&P, updated from previous notes with all of the day's events taken into consideration.

At the end of the note documentation process, valuable information about the patient has been collected and recorded in the EMR. Before the data is tabulated, however, it is usually integrated with clinical codesets. Let's discuss clinical codesets in the next section.