Which components are included in the SOAP method of documentation?

The SOAP method of documentation is a widely used framework in healthcare, particularly for recording patient interactions and assessments. The acronym stands for Subjective, Objective, Assess, and Plan.

• Subjective data refers to the patient's perceptions and feelings about their condition, often gathered through direct dialogue or interviews. This might include their description of symptoms, pain level, or emotional state, capturing their personal experience related to the ailment.

• Objective data is based on observable and measurable information obtained through physical examinations, assessments, or diagnostic tests. This includes vital signs, lab results, or any findings that can be noted by healthcare providers.

• Assess involves synthesizing the subjective and objective information to form a clinical judgment or diagnosis. This evaluation helps in understanding the patient's condition based on all gathered data.

• Plan refers to the specific actions that will be taken to address the patient's needs, including treatment options, further assessments, and follow-up care. This component outlines the strategy for managing the patient's condition moving forward.

Understanding this framework is crucial for effectively documenting clinical encounters and ensuring continuity of care in wilderness and remote first aid scenarios.