SOAP

Question 0

O (objective , observation)

Answer 0

Record your physical findings, including general appearance, vital signs and finding of system examination. Only that which you can see, hear, touch, smell, taste, along with age, chart and family information, laboratory tests, etc.

Question 1

S (Subjective)

Answer 1

Document information that is relevant to the current visit that you obtain by talking to the patient . This may include patient identification, chief complaint, history of present illness, past medical history, System review, social and / or sexual history information . ( headaches, depression, aches , pains) WHAT THE PATIENT TELLS YOU BUT YOU CANT SEE IT