SOAP Flashcards
1
Q
What is the SOAPS approach
A
S- subjective
O- objective
A- assessment plan
P- plan
S- safety netting
2
Q
Subjective
A
Interview (history)
1. Establish rapport with patient
-meet and greet
- respect and confidentiality
- primary presenting problem
- precise reason for visit - History of presenting problem
-symptoms
-how long
-their duration - other medical history
-illnesses
- hospitalizations/ operations
- allergies/ on any medication etc. - Family history
- illness - personal and psycho- social history
- feelings and ideas and fears of illness
-any loss of function from the illness
-expectation from this consultation
- family/ friends/ neighbors/ church/ faith
- SES, work etc - systemic enquiry
- general
-abdominal/ CNS
-respiratory/ CVS etc
3
Q
Objective
A
- Examination
- General
- Respiratory/ CVS
-Abdominal/ CNS
-Musculoskeletal etc - Investigations
- Side room tests (Hb/ ESR/ Urine/ Blood Glucose etc)
-Other tests (ECG/ X- Rays/ Scans. FBC/ U&E etc)
4
Q
3 stage assessment
A
Clinical
Individual
Contextual
5
Q
Clinical
A
- diagnosis
- undiagnosed symptoms
- reversible risk factors
- other relevant risk factors
6
Q
Individual
A
1) beliefs / ideas about cause of illness
2) feelings illness elicits – anger, frustration, depression
3) concerns / fears regarding illness – is it cancer doctor?
4) any loss of function – at work, home or socially?
5) what are patient’s expectations from this consultation? – medication, X-rays, med certificate
7
Q
Contextual
A
Family/ Sports/ Hobbies/ Support/ Church/ SES/ Environment/ Employment/ Faith/ Culture
8
Q
Plan
A
- Pharmacological
- Non pharmacologic plan
9
Q
Non pharmacological plan
A
- Social worker
- Motivational Interviewing
- Dietician
- Education and support
- Lifestyle modifications
- Sleep and stress management
-Monitoring and follow up
