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Created by Dr. Lawrence (“Larry”) Weed in 1966. Dr. Weed believed that the way in which data are recorded in the medical record ends up shaping the way we reason - hence the importance of having a method adequate to guide our registration and reasoning!
The term SOAP refers to the part of the Problem-Oriented Health Record (RMOP) that makes up the evolution of care in Primary Care. When using the term registration, it refers to RMOP, which has been used in several PHC systems around the world, and its use has expanded with the computerization of medical records. One of the objectives of the SOAP method is to be a tool work that makes it possible to analyze, compare and diagnose clinical emotional and behavioral changes.
In other words, it does not work with a simple data organization tool, but mainly as a means of qualifying clinical reasoning and the care offered. This is a process that requires method, skill and competence. The method is given by the organization of the consultation, the skills, the technical and clinical knowledge. Its main objectives are:
- Allow quick access to the person's data;
- Allow continued annotation of all problems;
- Accounting and evaluating the frequency of consultations;
- Obtain data to plan preventive and early diagnosis actions;
- Facilitate the continuing education of the doctor;
- Use data source for research.