SOAP note are used to document patient’s data using a common formats by health care providers

Subjective: To describe the patient narratively about the patient main complaint and why the patients
came to the doctor ( ex: pain in the gut )

Objective: to document the facts of the patient’s status repeatedly and objectively ( ex: face seemed to
be enduring the pain )

Assessment: evidence from the written records of medical dignoses made by the physician during the
medical visit ( ex: acute pain )

Planning: what the physician will do to treat for the patient’s ( ex: deep breath relaxation techniques )

Contoh format: