College of Massage Therapists of British Columbia (CMTBC) Practice Exam

What does the acronym SOAP stand for in clinical documentation?

1. Standard Operating Assessment Protocol

2. Subjective, Objective, Assessment, Plan

3. Sequential Outline of Assessment Procedures

4. Systematic Observation and Analysis Process

The correct answer is: Subjective, Objective, Assessment, Plan

The acronym SOAP in clinical documentation stands for Subjective, Objective, Assessment, and Plan. This format is widely used in healthcare to organize patient information and treatment plans in a clear and systematic manner. The Subjective component refers to the information reported by the patient, including their symptoms, feelings, and personal experiences. This part is essential as it provides insight into the patient's perspective on their condition and helps practitioners understand how they perceive their health. The Objective section captures measurable data observed during the examination, such as diagnostic tests, physical findings, and vital signs. This information is critical for establishing a baseline and determining the patient's physical state. In the Assessment portion, the clinician synthesizes the subjective and objective data to arrive at a clinical judgment or diagnosis. This part ties together what the patient reports and what the clinician observes, forming a comprehensive understanding of the patient's condition. Finally, the Plan includes the proposed interventions, treatments, and follow-ups based on the assessment. This may involve setting goals for treatment, prescribing therapy, or recommending referrals to other professionals. This structured approach helps ensure that all pertinent information is documented, facilitating communication among healthcare providers and improving continuity of care for the patient.