Utah Master Esthetician Practice Exam

Which of the following is NOT part of the SOAP acronym in medical documentation?

1. Subjective

2. Observation

3. Assessment

4. Plan

The correct answer is: Observation

The correct answer is that "Observation" is not part of the SOAP acronym in medical documentation. SOAP stands for Subjective, Objective, Assessment, and Plan. In this framework, the "Subjective" portion captures the patient's personal accounts of their symptoms and concerns, often expressed in their own words. The "Objective" section includes measurable data obtained through physical examinations and tests, presenting clinical findings that the practitioner observes. Next, the "Assessment" entails the clinician's interpretation of the subjective and objective information, leading to a diagnosis or progress evaluation. Finally, the "Plan" outlines the strategy for treatment based on the assessment, detailing next steps, interventions, or referrals. Understanding these components is crucial for effective medical documentation, and recognizing that "Observation" does not fit within this well-established structure helps clarify its essential elements.