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HLHS 101 09F - SOAP

S. O. A. P. - four general parts of a medical note - subjective, objective, assessment, plan
put simply, what is the subjective? - the problem in the patient's own words
what is included in the subjective? - duration of the problem, quality of the problem and any exacerbating or relieving factors for the problem
what is included in the objective - data comprised of the patient's physical exam, any laboratory findings and imaging studies performed at the visit
what is an assessment? - logical analysis formed after gathering pertinent information
what is included in the assessment? - diagnosis, identification of a problem, or a differential diagnosis (list of possible diagnoses)
what is a plan? - course of action consistent with the assessment - treatment with medicine or a procedure, collecting further data, etc.
subjective: acute - started recently - sharp, severe symptom
subjective: chronic - has been going on for a while
subjective: exacerbation - getting worse
subjective: abrupt - all of a sudden
subjective: febrile - to have a fever
subjective: afebrile - to not have a fever
subjective: malaise - not feeling well
subjective: progressive - more and more each day
subjective: symptom - something a patient feels
subjective: noncontributory - not related to this specific problem
subjective: lethargic - decrease in level of consciousness - generally a sign of the patient being "really sick"
subjective: genetic/hereditary - runs in the family
objective: alert - able to answer questions - responsive, interactive
objective: oriented - being aware of one's self, where one is, current time - aware of all 3 is "oriented x3"
objective: marked - really stands out
objective: unremarkable - normal
objective: auscultation - to listen
objective: percussion - to hit something and listen to the resulting sound or feel for vibration
objective: palpation - to feel
assessment: impression - assessment
assessment: diagnosis - what the health care professional thinks the patient has
assessment: differential diagnosis - a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
assessment: benign - safe
assessment: malignant - dangerous
assessment: degeneration - to be getting worse
assessment: etiology - the cause
assessment: remission - to get better or improve - does NOT mean cure
assessment: idiopathic - no known specific cause; just happens
assessment: localized - stays in a certain part of the body
assessment: systemic/generalized - all over the body (or most of it)
assessment: morbidity - the risk for being sick
assessment: mortality - the risk for dying
assessment: prognosis - the chances for things to get worse or better
assessment: occult - hidden
assessment: pathogen - the organism causing the problem
assessment: lesion - diseased tissue
assessment: recurrent - to have again
assessment: sequelae - problem resulting from a disease or injury
assessment: pending - waiting for
plan: disposition - what happened to the patient at the end of the visit
plan: discharge - to send home; unload the patient from care
plan: prophylaxis - preventive treatment
plan: palliative - treating the symptoms but NOT ridding the cause
plan: observation - watch, keep an eye on
plan: reassurance - to tell the patient that the problem is not serious or dangerous
plan: supportive care - to treat the symptoms and make the patient feel better
plan: sterile - extremely clean, germ-free conditions
Created by: claibornehouser
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