Lecture 01 Soap Note Flashcards
1
Q
What are the general meanings of SOAP note?
A
S=subjective= what you learn by taking patient history O=objective= exam including structural findings, lab, radiology data A=assessment= what you think is going on with patient P=plan= what you and patient agree to do about the problem (including OMT performed)
2
Q
Subjective:
A
- CC
- HPI
- PMH (other active prob)
- PSH
- Meds
- allergies
- Social/family hx
- ROS
3
Q
Objective:
A
- exam findings (full or focused)
- lab data
- radiology data
4
Q
Assessment:
A
- not always a dx
- basic description of the problem (restatement of CC)
5
Q
HPI (history or present illness)
A
-this “age/race/gender” resports…. Historical data related to CC, associated symptoms