SOAP Categories and Key Info
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| S. O. A. P With Charting Colors | SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN -
COLORS: (S) BLUE (O) RED (A) YELLOW (P) GREEN
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| SUBJECTIVE - 'S' | PROBLEM(S) IN PATIENT'S OWN WORDS. MAIN REASON FOR VISIT. (CC) TIMING & QUALITY OF PROBLEM.
CURRENT MEDS AND ALLERGIES
DETAILS Of Hx, PMHx, FHx, Past Surgeries & Social Hx.
EXACERBATING OR RELIEVING FACTORS
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| OBJECTIVE - 'O' | COLLECTION OF DATA COLLECTED FROM PHYSICAL EXAM, LABS, XRAYS AND DIAGNOSTIC STUDIES PERFORMED AT A VISIT. HOW DOES Pt. LOOK, SOUND, FEEL, SMELL.
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| ASSESSMENT - 'A' | HEALTH PROVIDER'S FORMULATED, LOGICAL ANALYSIS.
"ASSESSMENT" - A DIAGNOSIS, IDENTIFICATION OF A PROBLEM, LIST OF POSSIBILITIES (DDx The Differential Diagnosis)
SEVERITY OF PROBLEMS AND CHANCES OF IMPROVEMENT. PROGNOSIS.
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| PLAN - 'P' | COURSE OF ACTION CONSISTENT WITH AN ASSESSMENT.
TREATMENTS: Surgical, Medication, A Procedure. Wait & See.
FURTHER TESTING PLAN TO CONFIRM/ARRIVE AT A MORE ACCURATE DIAGNOSIS. FURTHER TESTS.
RECOMMENDATIONS AND REFERRALS.
HOME REMEDIES AND F/U's.
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| CLINICAL NOTE - AT A CLINIC - ( SOAP) | DONE BY MEDICAL PROFESSIONAL.
PURPOSE: TO DOCUMENT A VISIT.
NEW Pt. INCLUDES MORE Hx.
REPEAT Pt. STREAMLINED NOTE.
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| CONSULT NOTE - CLINIC OR HOSPITAL - (SOAP) | DONE BY A SPECIALIST.
PURPOSE: PROVIDES EXPERT OPINION ON MORE CHALLENGING PROBLEM.
CAN BE IN THE FORM OF A LETTER TO A PCP.
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| EMERGENCY DEPARTMENT (ED) NOTE - (SOAP) | DONE BY ED MEDICAL STAFF.
PURPOSE: DOCUMENTS AN ER/ED VISIT.
'A' Includes the ED course.
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| ADMISSION SUMMARY - HOSPITAL - (SO, A/P) | DONE BY HOSPITAL MEDICAL PROFESSIONAL.
PPURPOSE: DOCUMENTS ADMISSION OF Pt. TO THE HOSPITAL.
S, O = Very Thorough - A = DDx - P = Further Testing & Care
A+P = Problem Based-Approach
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| DISCHARGE SUMMARY - HOSPITAL - (ASOP) | DONE BY MEDICAL PROFESSIONAL.
PURPOSE: DESCRIBES WHEN & WHY Pt. WAS ADMITTED; DOCUMENTS A LONGER STAY.
STARTS WITH 'A'.
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| OPERATIVE REPORT - (ASOP) | DONE BY SURGEON. DOCUMENTS A DETAILED SURGERY.
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| DAILY HOSPITAL NOTE/PROGRESS NOTE - IN PATIENT HEALTHCARE FACILITY - (SO, A/P) | DONE BY A MEDICAL PROFESSIONAL.
PURPOSE: DOCUMENTS A DAILY HOSPITAL VISIT.
S = FOCUSES ON HOW Pt. CONDITION HAS CHANGED, SINCE PREVIOUS NOTE.
A - SOMETIMES, INCLUDES DDx.
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| RADIOLOGY REPORT - (SOA) | DONE BY A RADIOLOGIST.
PURPOSE: EXPLAINS REASON FOR IMAGE, HOW IT WAS PERFORMED, WHAT WAS SEEN, RADIOLOGIST'S ASSESSMENT; SOMETIMES A RECOMMENDATION.
MAY INCLUDE 'P', IF FURTHER STUDIES ARE RECOMMENDED.
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| PATHOLOGY REPORT - (SOA) | DONE BY A PATHOLOGIST.
PURPOSE: PROVIDES REASONS FOR TESTS, WHAT WAS SEEN & AN ASSESSMENT.
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| PRESCRIPTION - (P) | WRITTEN BY A MEDICAL PROFESSIONAL.
PURPOSE: DIRECTIONS FOR MEDICATION(S).
LINES: 1. MED NAME
2. Pt. INSTRUCTIONS
3. HOW MUCH MED TO BE GIVEN
4. REFILLS (IF ANY)
5. PROVIDER'S SIGNATURE AND GENERIC SUBSTITUTION.
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| S - SUBJECTIVE - COMMONLY FOUND ABBREVIATIONS & TERMS | DOB, Pt. CC, HPI, PMHx, PAST SURGICAL HISTORY, FHx, SOCIAL Hx. ROS, H&P
ACUTE, CHRONIC, ABUPT, MALAISE, CHRONIC
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| O - OBJECTIVE - COMMONLY FOUND ABBREVIATIONS & TERMS | VS, T, RR, RRR, BP, BMI, A&O, I/O, SOB, PERRLA, NAD, WDWN, WNL, NOS, NEC, CTA, PE, TM, HEENT, XRAYS, LABS, IMAGING, FINDINGS
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| A - ASSESSMENT - COMMONLY FOUND ABBREVIATIONS & TERMS | Dx, DDx, BENIGN, MALIGNANT, PENDING, PROGNOSIS, IMPRESSION
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| P - PLAN - COMMONLY FOUND ABBREVIATIONS & TERMS | f/u, DISCHARGE, OBSERVATION, PALLIATIVE, SUPPORTIVE CARE, Recommendation, Disposition, PCP, DDx, Tx, Rx, PO, NOS, PR, SC, IV, CVL, PICC, Sig, ad lib, BID, TID, QD, QID, QHS, AC, PPC, prn
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Created by:
MCasler
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