Which acronym represents the documentation format that includes subjective, objective, assessment, and plan?

• A. EMR
• B. Charting
• C. SOAP
• D. DICOM

Answer: (C)

SOAP notes provide a structured way to document a patient encounter. The Subjective portion captures what the patient reports—symptoms, history, and concerns. The Objective portion lists what the clinician observes or measures—vital signs, physical exam findings, and test results. The Assessment portion contains the clinician’s diagnosis or impression, including any differential diagnoses if relevant. The Plan portion outlines the next steps—treatment, medications, further tests, patient education, and follow-up.

This format is specifically named SOAP because it names each of the four parts. EMR refers to the electronic medical record system where such notes are stored, not the format itself. Charting is a general term for documenting patient information and can follow various formats, not necessarily SOAP. DICOM is a standard for medical imaging data, not a documentation structure.