One of the most common documentation frameworks clinicians use for patient evaluations are Subjective, Objective, Assessment, and Plan, (SOAP) notes. The clinician will usually record medical, family, social, etc. history as “subjective” information. Temperature, blood pressure, lab work, etc. would be considered “objective” information. An evaluation of the patient’s health and possible medical issues would be considered the “assessment,” and their intentions for current and future treatment would be the “plan” within these notes. Trainees often write SOAP notes after completing a standardized patient (SP) encounter—an educational practice used in medical schools to simulate real-world physician-patient interactions in order to develop and assess clinical reasoning skills. A standardized patient is employed to act as a patient, memorizing and reciting previously delineated information provided by medical educators.
Popescu, M. M., Noonan, E. J., & Weingartner, L. A. (2021). Gender Identity and Pronoun Usage in Standardized Patient Encounters., 2020 Retrieved from https://ir.library.louisville.edu/gcp/vol2020/iss/1