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HLHS 101 09F - SOAP
| Term | Definition |
|---|---|
| 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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