What format does a SOAP report use for documentation?

The SOAP report format is widely used in medical and psychological documentation, making the first choice the correct one. It stands for Subjective, Objective, Assessment, and Plan, which organizes information systematically to facilitate communication among healthcare providers.

In this format:

• Subjective refers to the patient's personal reports about their condition, including feelings, experiences, and symptoms, which offer insight into their health from their perspective.

• Objective involves factual, measurable data collected during the examination, such as vital signs, lab results, and physical findings that provide a tangible basis for the patient's condition.

• Assessment is the clinician's interpretation of the subjective and objective data, leading to a diagnosis or clinical judgment regarding the patient’s state.

• Plan outlines the next steps in the patient’s treatment or management, including interventions, referrals, or follow-up strategies.

This organization allows practitioners to quickly understand a patient’s situation and facilitates a clear approach to care. Other options do not align with the established terminology and methodology of the SOAP format, rendering them incorrect in this context.