Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

What Is SOAP?

SOAP involves the abstraction of clinical information from patient records in a defined scope with specific procedures. SOAP is a ten-step clinical content data analysis tool that allows analytics of the content of the record. The following is the breakdown of SOAP:

S—Subjective: patient information, or what the patient tells you. This may be documented as an actual quote or a paraphrased statement by the provider. At minimum, it should address the issue for which the patient sought treatment.

O—Objective: patient data elements, or what the professional observes, measures, assesses, or analyzes from the assessments or diagnostics. At minimum, it should relate to the patient’s statement.

A—Assessment: a list of diagnoses and patient problems. At minimum, assessment includes the problem the narrative is addressing in its findings. The assessment should be associated with the patient’s statements and the objective findings noted.

P—Plan: a list of all treatment protocols. At minimum, this includes the activities associated with the problem identified, the objective data collected, and the patient’s statement.

The above information is collected and then an evaluation is based on the response to each of the above categories. The collection of data elements repeats itself. Any audit or investigation at some point will generate a written report. That report may be utilized internally, with external parties, or eventually be presented during the course of formal litigation. ...