What type of information is included in the Plan section of the SOAP note?

The Plan section of the SOAP note is crucial as it outlines the recommended future steps and interventions tailored to address the patient's needs based on the assessment performed. This includes any proposed treatments, diagnostic tests, referrals to specialists, follow-up appointments, and educational information provided to the patient. By clearly stating the action items, the Plan allows for continuity of care and sets the direction for the patient's ongoing treatment.

While patient history and current medications are essential components of the medical record, they belong to other sections of the SOAP note—history in the Subjective section and current medications in the Objective section. Similarly, the Symptoms and findings are documented in the Subjective and Objective sections, reflecting the patient's experience and the clinician's observations. Therefore, the focus of the Plan section is distinct and specifically related to the path forward in managing the patient's health scenario.