 SOAP is an acronym for:  S ubjective - What the patient says about the problem / intervention.  O bjective - The therapists objective observations and treatment interventions (e.g. ROM, Outcome Measures)Outcome Measures  A ssessment - The therapists analysis of the various components of the assessment.  P lan - How the treatment will be developed to the reach the goals or objectives

 This component is in a detailed, narrative format and describes the patients self-report of their current status in terms of their function, disability, symptoms and history. It may also include information from the family or caregivers and if exact phrasing is used, should be enclosed in quotation marks. It allows the therapist to document the patients perception of their condition as it relates to their progress in rehabilitation, functional performance or quality of life.  Common errors:  Passing judgement on a patient e.g. "Patient is over- reacting again".  Documenting irrelevant information e.g. patient complaining about previous therapist.

 This section outlines the objective results of the re-assessment, the progress towards functional goals and the treatments performed. It should include details of the interventions, including frequency, duration and equipment used. The therapist should indicate changes in the patient's status, as well as communication with colleagues, family or careers.  Common errors:  Scant detail is provided.  Global summary of an intervention e.g. "ROM exercises given"

 This is potentially the most important legal note because this is the therapists professional opinion in light of the subjective and objective findings. It should explain the reasoning behind the decisions taken and clarify and support the analytical thinking behind the problem-solving process. Progress towards the stated goals are indicated, as well as any factors affecting it that may require modification of the frequency, duration or intervention itself. Adverse, as well as positive responses should be documented.  Common errors:  The assessment is too vague e.g. "Patient is improving".  Little insight is provided

 The final component of the note is used to outline the plan for future sessions. The therapist should report on what the patient's Home exercise programme (HEP) will consist of, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy are documented in this section.  Common errors:  The upcoming plan is not indicated.  Vague description of the plan e.g. "Continue treatment"