What is SOAP?
SOAP stands for Subjective, Objective, Assessment, and Plan — a widely adopted framework for documenting clinical encounters. It provides a clear, consistent structure that supports efficient communication and continuity of care across healthcare settings.
📝 What is SOAP?
SOAP stands for Subjective, Objective, Assessment, and Plan — a widely adopted framework for documenting clinical encounters. It provides a clear, consistent structure that supports efficient communication and continuity of care across healthcare settings.
SOAP is used extensively in general practice, specialist consults, nursing, allied health, and mental health services throughout Australia and New Zealand.
✏️ Structure
| Section | Description |
|---|---|
| Subjective | Information shared by the patient — symptoms, concerns, and relevant context. |
| Objective | Measurable or observed clinical data — exam findings, vitals, and investigations. |
| Assessment | Clinician's clinical impression, diagnosis, or working hypothesis. |
| Plan | Next steps — treatment, further testing, referrals, or follow-up. |
🔀 How SOAP is adapted for different specialties
Echo-Health supports SOAP formats that reflect the documentation needs of various clinical contexts. The core structure remains the same, but emphasis and language may shift based on the setting:
| Specialty | Notes on Adaptation |
|---|---|
| General Practice | Standard format. Used across consult types. Can be merged into “Assessment & Plan” for brief visits. |
| Nursing | Focus is on objective observations and care planning. Commonly paired with structured care tasks. Often used in aged care, wound management, and chronic disease monitoring. |
| Psychiatry | Greater emphasis on subjective detail and mental status examination. Objective may capture appearance, speech, and behaviour more than physical exam. |
| Emergency Medicine | Prioritises rapid assessment and action. Often merges Assessment & Plan and includes triage-level observations. |
| Oncology | SOAP may include structured cancer staging, medication history, and coordinated care plans. |
| Well Child / Paediatrics | Adjusted to capture developmental milestones and family input, with age-appropriate assessment detail. |
| Lactation Consults | Subjective and objective sections include breastfeeding concerns, latch assessment, and infant weight tracking. Plan includes feeding guidance and referrals if needed. |
These adaptations help ensure that documentation reflects both clinical complexity and the expectations of specific care environments — while preserving consistency across the care team.
🏥 When is it used?
-
Standard GP consultations
-
Specialist reviews
-
Allied health and nursing documentation
-
Mental health sessions
-
Telehealth and urgent care
🌍 Where is it available?
SOAP is supported across both Australia and New Zealand, with format variations configured by jurisdiction and mapped to relevant clinical specialties within Echo-Health.