SOAP Flashcards
Refers to whether
symptoms have a set pattern, such as occurring every
evening.
TEMPORAL PATTERNS
The diagnosis or condition
the patient has.
ASSESSMENT
Determine if there are other symptoms.
SYMPTOMS-ASSOCIATED
Involves factors you can measure, see, hear, feel or
smell.
OBJECTIVE
This refers to how you are going to address the
patient’s problem.
PLAN
This refers to subjective observations
that are verbally expressed by the patient,
such as information about symptoms.
SUBJECTIVE
A method of
documentation employed by health care
providers to write out notes in a patient’s
chart.
SOAP PROGRESS NOTE
An organized summary of all known patient
information.
PATIENT CASE PRESENTATION
Reason why a patient seeks medical attention.
CHIEF COMPLAINT
Information about the patient’s occupation, marital
status, sexual history and living conditions
SOCIAL HISTORY
o Menarche
o Menopause
o History of sexual contact
o Contraception
o Pregnancy
OB-GYNE HISTORY
Summarizes all current patient complaints not included in HPI
REVIEW OF SYSTEMS
Inspection, palpation, percussion and
auscultation
PHYSICAL EXAMINATION
Includes brief description of patient problems
unrelated to the present illness
PAST MEDICAL HISTORY
Consist a brief summary of the medical histories of
the patient’s first degree relatives
FAMILY HISTORY
Obtaining this is the 1
st step of medicine
reconciliation process
MEDICATION HISTORY
Primary diagnosis
ADMITTING DIAGNOSIS
Brief enumeration of the patient’s problems, starting
with the most acute problem.
PATIENT PROBLEM LIST AND INITIAL PLANS
Presented after the physical assessment
section of the patient case
LABORATORY AND DIAGNOSTIC TEST RESULTS
Consists of a list of all medicines taken by the
patient prior to admission.
MEDICATION HISTORY
Presented and documented in the patient’s own
words.
HISTORY OF PRESENT ILLNESS
Refers to what area of the body hurts.
LOCATION
Refers to the type of pain, such as stabbing, dull or aching.
CHARACTER
Determine if anything reduces or
eliminates symptoms and if anything makes them worse.
ALLEVIATING FACTORS
