title: The essential SOAP note in an EHR age.
abstract: This article reviews the traditional Subjective, Objective, Assessment, and Plan (SOAP) note documentation format. The information in the SOAP note is useful to both providers and students for history taking and physical exam, and highlights the importance of including critical documentation details with or without an electronic health record.
authors.affiliation: Patricia F. Pearce is an associate professor at Loyola University School of Nursing in New Orleans, La. Laurie Anne Ferguson is an associate professor at Loyola University, School of Nursing, New Orleans, La. Gwen S. George is an associate professor at Texas A & M International University, Laredo, Tex. Cynthia A. Langford is an associate professor at Loyola University, School of Nursing, New Orleans, La.
authors.forename: Patricia F
authors.initials: PF
authors.lastname: Pearce
authors.forename: Laurie Anne
authors.initials: LA
authors.lastname: Ferguson
authors.forename: Gwen S
authors.initials: GS
authors.lastname: George
authors.forename: Cynthia A
authors.initials: CA
authors.lastname: Langford
mesh_terms: D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records; D006801:Humans; D008487:Medical History Taking; D009737:Nursing Records; D010808:Physical Examination / Q000451:nursing