Medical Auditing Practice Exam

In Evaluation and Management documentation, what does the acronym SOAP stand for?

1. Service, Observation, Assessment, Plan

2. Subjective, Objective, Assessment, Plan

3. Summary, Outline, Assessment, Procedure

4. Standard, Outcome, Analysis, Plan

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

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. This format is a widely used method for documenting patient encounters in the medical field. The 'Subjective' section includes information provided by the patient regarding their condition, symptoms, and concerns, capturing their perspective and experiences. The 'Objective' portion contains measurable and observable data collected during the examination, including vital signs, lab results, and physical findings. The 'Assessment' component synthesizes the subjective and objective information to arrive at a diagnosis or clinical impression. Finally, the 'Plan' outlines the next steps for managing the patient's care, which may include further testing, treatment options, or referrals. This structured approach is valuable because it provides a clear and organized way to assess a patient's condition, ensuring that all critical aspects of the evaluation are covered and easily accessible for future reference. The use of this methodology aids in continuity of care and enhances communication among healthcare providers.