SOAP Flashcards
information you have learned from the patient
subjective
it describes patient’s condition in narrative form
subjective
subjective data consists 2 parts
chief complaint and hpi
brief statement of the patient quoted as the purpose of the visit
chief complaint
patient’s condition in narrative form
history of present illness
hpi includes
onset, chronology, quality, severity, modifying factors, additional symptoms, treatment
documents repeatable and traceable facts about the patient’s status
objective data
objective data includes: (4)
- vital signs (pulse rate, temperature, blood pressure, respiratory rat)
- lab results
- findings from physical examination (posture, bruising, abnormalities)
- age and weight
occurs during the maximal contraction of the heart
systolic pressure
resting pressure
diastolic pressure
normal bp
120/80
physical expansion of the artery
pulse rate
normal pulse rate of newborn, toddler, older child, adolescent, adult
- newborn - 130-150
- toddler - 100-120
- older child - 60-100
- adolescents - 80-100
- adults - 50-80
normal range of respiratory rate
16-20 breaths per minute
main reason for checking body temperature
solicit any signs of infection and inflammation in the presence of fever
normal body temperature
not more than 38.5 c
Physician’s medical diagnoses for the medical visit on the given date of a note written.
assessment
This describes what the health care provider will do to treat the patient
plan
treatment plan should be dividede into (4)
- diagnostics
- therapeutic
- patient education
- health promotion strategies
purpose of documentation
- legal document
- method of communication
- reimbursement of third party payers
- discharge decisions
guidelines in writing soap
accuracy, brevity, clarity, correcting errors
