The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan.
Subjective
This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them.
Objective
This section documents the objective data from the patient encounter. This includes:
Assessment
This section documents the combining of “subjective” and “objective” evidence to arrive at a possible diagnosis.
Plan.