Common Terms in Medicine (SOAP method)

Question 1

Subjective

Answer 1

These are the problems that the patient states he/she has. Those problems are then translated into medical terms.
This is so that you can correctly communicate the problems to all health care providers

Question 2

Objective

Answer 2

This is the data collected by the health care provider. This information also includes data obtained from lab tests or special images of the patient’s body.

Question 3

General Subjective Terms examples

Answer 3

Acute vs. chronic
Abrupt
Febrile vs. afebrile
Malaise
Progressive vs. exacerbation
Symptom
Noncontributory
Lethargic
Genetic/hereditary

Question 4

General Objective Terms examples

Answer 4

Things that are seen:
Alert
Oriented
Things that are heard:
Auscultation
Percussion
Things that are felt:
Palpation
Descriptions of what is observed:
Unremarkable

Question 5

Assessment

Answer 5

This is the combination of the subjective and objective information.
This information leads to a conclusion about the problem known as the diagnosis.
If a single cause isn’t evident, a differential diagnosis—a list of the most likely causes—may be needed

Question 6

General Assessment terms

Answer 6

Morbidity - the condition of suffering from a disease
Mortality - the likelihood of death
Prognosis - likely outcome
Localized vs. systemic/generalized
Occult - hidden
Pathogen - thing causing disease
Lesion
Sequelae - result of
Pending - on hold

Question 7

Plan

Answer 7

The plan is what the provider recommends to the patient regarding their current health status.
This can include medication, surgery, and/or further tests, among other options.

Question 8

General Plan terms

Answer 8

Disposition - destination of the patient after discharge
Discharge
Prophylaxis
Palliative
Observation
Reassurance
Supportive care
Sterile