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SOAP
SOAP method definitions
Term | Definition |
---|---|
subjective | how pt feels, describes his problem, PMHx, FHx, in own words, exacerbating or relieving factors |
objective | PT PE, RR, HR, T, BP , lab findings and imaging results at this visit |
assessment | Dx, DDx, identification of problem |
plan | course of action/treatment plan, rx, procedure, surgery more test etc |