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SOAP Method

Chapter 2 introduces you to the SOAP Method.

QuestionAnswer
SOAP An acronym that stands for the four general parts of a medical note: Subjective,Objective,Assesment, and Plan.
Subjective subject to how a patient experiences and personally describes their problem as well as personnel and family medical histories. it is the problem in the patient's own words.
Objective data collected to assist in understanding the nature of the problem. Ex: physical exam, lab findings, and imaging finding.
SOAP Note pattern used in writing medical terms.
Assessment Cause of the problem. Ex: a diagnosis, an identification of the problem.
Plan Treatment with medicine or a procedure.
differential diagnosis A list of possible causes of the patients problem or complaints.
Examples of Objective lab results, initial imaging studies ( x- ray), and patient's exams.
examples of Subjective Past medical history, family history, and determination on how long the patient has suffered from the same complaint.
Ex of Assessment Diagnosis, an identification of the cause of the problem or complaint, and differential diagnosis.
Ex of Plan Scheduling a surgery, ordering more tests or images, medicinal treatment
Chief complaint main reason for the patient's visit
History of present illness story of the patient's problem
review of systems Description of individual body systems in order to discover any symptoms not directly related to the main problem
Past Medical history Other significant past illnesses that run in the patient's family
Social history a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
Created by: Bpadilla12
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