SOAP Flashcards
Soap and ISBAR difference?
SOAP is the documentation for healthcare providers in an organized way whilst ISBAR is communication between health care to transfer data.
what is the Subjective part of SOAP?
It refers to the personal views of a patient from a feeling point of view, in other words, is a subjective experience. it provides context for assessment and planning.
what is the difference between signs and symptoms in the SOAP context?
- Symptoms are what a patient describes from the presenting complaint whilst signs are what the clinician finds relative to the patient subjective description of the complaint by doing text and examination. therefore, symptoms seats in the subjective part, and signs are objective
how To elaborate on the history of presenting illness in the subjective part of soap?
an acronym used to organsie HPI is termed OLDCARTS
Onset: When did the CC begin?
Location: Where is the CC located?
Duration: How long has the CC been going on for?
Characterization: How does the patient describe the CC?
Alleviating and Aggravating factors: What makes the CC better? Worse?
Radiation: Does the CC move or stay in one location?
Temporal factor: Is the CC worse (or better) at a certain time of the day?
Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC
SOAP format general activity question in Subjective part?
Do you play any sports?
How often do you play/train?
What level are you participating at?
Do you do any walking during the day?
What surfaces are you working/playing on?
What shoes do you wear whilst exercising?
- type, duration, frequency and load, surface and footwear
Soap format general pain question
Where is the pain? (Ask the patient to show you)
Type of pain – Burning, stinging, dull ache…..?
How often does it hurt?
What activities or movements cause the pain?
Does it radiate or stay localized?
Does the pain continue at rest/sleeping?
Is the pain bad enough to wake you up at night?
Does it feel like it’s the outside or the inside that hurts?
MEASURE IT** - On a scale of 0-10 (10= the worst pain you have ever experienced), what would you rate
the pain?
How to approach taking subjective information from a patient?
- Open ended questions (not leading) – ‘Tell me about your foot problem’? vs
‘Is your foot sore’ - Affirmation – ‘I agree, it would be affecting your work if your foot hurts for
most of the day’, ‘It’s great you are seeking help for this’ - Reflection – ‘So it’s painful when you first get up but gets better if you walk
for a minute or two?’ - Summarising – ‘So your left foot hurts when you go to walk after sitting for
awhile and this started a few months ago when you began your current office
job?’ - 1- Open ended question, affirmation, reflection, summarising
after this, then build a picture like this example:
g. Do you play sport? What type of sport and how often? How long
do you stand/sit for each shift? What sort of flooring is it? How often
do you change your running shoes? Etc.
Narrowing down (for confirmation): - E.g. It hurts after soccer but not swimming? So you stand for about 5
hours a day and it’s a concrete floor? So, you started wearing a heeled
shoe with the new job? - finally end the subjective information by
What do you think is causing your pain/concern?
Is there anything else you would like to tell me? - Always check red flags
Risk stratification table
find it in uni onederive, pod 300, review
difference between categorizing diabetic foot risk and none diabetic foot risk in the assessment part
- write down pt on —- risk of foot ulcer for diabetic
- wirte down pt is on — risk of foot COMPLICATION
in an emergency situation assessing vital is important. it includes
Blood pressure and pulse
look beyond the foot
1- appearance E.g, related to weight
2- Distress and pain, severe pain to the point she refuses to weight bear
3- anxiety or depression
4- self-neglect, the client appears ungroomed
SOAP writing format
-follow the ISBAR order. However, the objective part is speparate.
* if the patient has done the assessment recently, you still need to ask if there has been any chages to medication and the reason pt is here
- Also, check the pulses is always a requirement
