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S.O.A.P Cards

SOAP Categories and Key Info

PARTDATA
S. O. A. P With Charting Colors SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN - COLORS: (S) BLUE (O) RED (A) YELLOW (P) GREEN
SUBJECTIVE - 'S' PROBLEM(S) IN PATIENT'S OWN WORDS. MAIN REASON FOR VISIT. (CC) TIMING & QUALITY OF PROBLEM. CURRENT MEDS AND ALLERGIES DETAILS Of Hx, PMHx, FHx, Past Surgeries & Social Hx. EXACERBATING OR RELIEVING FACTORS
OBJECTIVE - 'O' COLLECTION OF DATA COLLECTED FROM PHYSICAL EXAM, LABS, XRAYS AND DIAGNOSTIC STUDIES PERFORMED AT A VISIT. HOW DOES Pt. LOOK, SOUND, FEEL, SMELL.
ASSESSMENT - 'A' HEALTH PROVIDER'S FORMULATED, LOGICAL ANALYSIS. "ASSESSMENT" - A DIAGNOSIS, IDENTIFICATION OF A PROBLEM, LIST OF POSSIBILITIES (DDx The Differential Diagnosis) SEVERITY OF PROBLEMS AND CHANCES OF IMPROVEMENT. PROGNOSIS.
PLAN - 'P' COURSE OF ACTION CONSISTENT WITH AN ASSESSMENT. TREATMENTS: Surgical, Medication, A Procedure. Wait & See. FURTHER TESTING PLAN TO CONFIRM/ARRIVE AT A MORE ACCURATE DIAGNOSIS. FURTHER TESTS. RECOMMENDATIONS AND REFERRALS. HOME REMEDIES AND F/U's.
CLINICAL NOTE - AT A CLINIC - ( SOAP) DONE BY MEDICAL PROFESSIONAL. PURPOSE: TO DOCUMENT A VISIT. NEW Pt. INCLUDES MORE Hx. REPEAT Pt. STREAMLINED NOTE.
CONSULT NOTE - CLINIC OR HOSPITAL - (SOAP) DONE BY A SPECIALIST. PURPOSE: PROVIDES EXPERT OPINION ON MORE CHALLENGING PROBLEM. CAN BE IN THE FORM OF A LETTER TO A PCP.
EMERGENCY DEPARTMENT (ED) NOTE - (SOAP) DONE BY ED MEDICAL STAFF. PURPOSE: DOCUMENTS AN ER/ED VISIT. 'A' Includes the ED course.
ADMISSION SUMMARY - HOSPITAL - (SO, A/P) DONE BY HOSPITAL MEDICAL PROFESSIONAL. PPURPOSE: DOCUMENTS ADMISSION OF Pt. TO THE HOSPITAL. S, O = Very Thorough - A = DDx - P = Further Testing & Care A+P = Problem Based-Approach
DISCHARGE SUMMARY - HOSPITAL - (ASOP) DONE BY MEDICAL PROFESSIONAL. PURPOSE: DESCRIBES WHEN & WHY Pt. WAS ADMITTED; DOCUMENTS A LONGER STAY. STARTS WITH 'A'.
OPERATIVE REPORT - (ASOP) DONE BY SURGEON. DOCUMENTS A DETAILED SURGERY.
DAILY HOSPITAL NOTE/PROGRESS NOTE - IN PATIENT HEALTHCARE FACILITY - (SO, A/P) DONE BY A MEDICAL PROFESSIONAL. PURPOSE: DOCUMENTS A DAILY HOSPITAL VISIT. S = FOCUSES ON HOW Pt. CONDITION HAS CHANGED, SINCE PREVIOUS NOTE. A - SOMETIMES, INCLUDES DDx.
RADIOLOGY REPORT - (SOA) DONE BY A RADIOLOGIST. PURPOSE: EXPLAINS REASON FOR IMAGE, HOW IT WAS PERFORMED, WHAT WAS SEEN, RADIOLOGIST'S ASSESSMENT; SOMETIMES A RECOMMENDATION. MAY INCLUDE 'P', IF FURTHER STUDIES ARE RECOMMENDED.
PATHOLOGY REPORT - (SOA) DONE BY A PATHOLOGIST. PURPOSE: PROVIDES REASONS FOR TESTS, WHAT WAS SEEN & AN ASSESSMENT.
PRESCRIPTION - (P) WRITTEN BY A MEDICAL PROFESSIONAL. PURPOSE: DIRECTIONS FOR MEDICATION(S). LINES: 1. MED NAME 2. Pt. INSTRUCTIONS 3. HOW MUCH MED TO BE GIVEN 4. REFILLS (IF ANY) 5. PROVIDER'S SIGNATURE AND GENERIC SUBSTITUTION.
S - SUBJECTIVE - COMMONLY FOUND ABBREVIATIONS & TERMS DOB, Pt. CC, HPI, PMHx, PAST SURGICAL HISTORY, FHx, SOCIAL Hx. ROS, H&P ACUTE, CHRONIC, ABUPT, MALAISE, CHRONIC
O - OBJECTIVE - COMMONLY FOUND ABBREVIATIONS & TERMS VS, T, RR, RRR, BP, BMI, A&O, I/O, SOB, PERRLA, NAD, WDWN, WNL, NOS, NEC, CTA, PE, TM, HEENT, XRAYS, LABS, IMAGING, FINDINGS
A - ASSESSMENT - COMMONLY FOUND ABBREVIATIONS & TERMS Dx, DDx, BENIGN, MALIGNANT, PENDING, PROGNOSIS, IMPRESSION
P - PLAN - COMMONLY FOUND ABBREVIATIONS & TERMS f/u, DISCHARGE, OBSERVATION, PALLIATIVE, SUPPORTIVE CARE, Recommendation, Disposition, PCP, DDx, Tx, Rx, PO, NOS, PR, SC, IV, CVL, PICC, Sig, ad lib, BID, TID, QD, QID, QHS, AC, PPC, prn
Created by: MCasler
 

 



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