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Chapter 2

S.O.A.P.

TermDefinition
subjective It is subject to how a patient experiences and personally describes his or her problem as well as personal and family medical histories.
objective Objective data comprise the patient’s physical exam, any laboratory findings, and imaging studies performed at the visit.
assessment An assessment could be a diagnosis, an identification of a problem, or a list of possibilities for the diagnosis which is known as a differential diagnosis.
plan The plan could be a treatment with medicine or a procedure. It could also consist of collecting further data to help arrive at a more accurate diagnosis
Created by: NayNay22931
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