[1] The SOAP note originated from the problem-oriented medical record (POMR), developed nearly 50 years ago by Lawrence Weed, MD.
[1][4] It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way.
[4] Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress.
[1] SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds.
[2] Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR.
[10] It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded.
[1] The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient's current presentation, such as: A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely.
When used in a problem-oriented medical record (POMR), relevant problem numbers or headings are included as subheadings in the assessment.