What goes in the plan of care portion of a SOAP note?

What goes in the plan of care portion of a SOAP note?

• A. The plan of care as determined by the clinician
• B. The clinician's diagnostic impression
• C. The patient consent
• D. Discharge instructions

Answer: (A)

The plan of care section describes what will be done next to treat the patient. It turns the information from the assessment into concrete actions: the chosen interventions or therapies, how often and for how long they will be done, specific goals and criteria for success, any necessary referrals or home programs, and how the patient will be educated and followed up. This is the clinician’s plan for moving the patient toward those goals. The diagnostic impression belongs in the assessment, where the clinician explains the reasoning and the diagnosis based on subjective and objective findings. Patient consent is documentation of agreement to treatment and is typically recorded separately from the plan of care. Discharge instructions pertain to leaving care or the next stage of care and are not the ongoing treatment plan, though they may be included when appropriate in discharge planning.

The plan of care section describes what will be done next to treat the patient. It turns the information from the assessment into concrete actions: the chosen interventions or therapies, how often and for how long they will be done, specific goals and criteria for success, any necessary referrals or home programs, and how the patient will be educated and followed up. This is the clinician’s plan for moving the patient toward those goals.

The diagnostic impression belongs in the assessment, where the clinician explains the reasoning and the diagnosis based on subjective and objective findings. Patient consent is documentation of agreement to treatment and is typically recorded separately from the plan of care. Discharge instructions pertain to leaving care or the next stage of care and are not the ongoing treatment plan, though they may be included when appropriate in discharge planning.