SOAP Flashcards
1
Q
SOAP and Other Components
A
Subject, Objective, Assement, Plan
Header, Signature
2
Q
Why and Where SOAP
A
- WHY?
- Continuity of care
- Pt saftey
- Insurnance billing, proper reimbursment
- Auditing and liability
- WHERE?
- Outpaitent
- Clinics
- Inpatient
- Meds started, changed or stopped
3
Q
Header and Subjective
A
- Header
- Pharmacy Note
- Age, gender, CC
- ID & CC: Patient age, gender, chief complaint
- HPI: History of Present Illness (SCHOLAR MAC)
- PMH: Past Medical History
- DH: Drug History
- Allergies
- FH: Family History
- SH: Social History
- ROS: Review of Systems
4
Q
Objective
A
- Current medication list (if verified)
- PE: Physical Exam
- VS: T, HR, BP, RR
- Vital signs: temperature, heart rate, blood pressure, respiratory rate
- Pertinenet labs:
- CrCl, BMI
- Microbiology
- Radiology
5
Q
Subjective vs. Objective
A
- Subjective:
- Not directly measurable
- Symptoms
- Provided by the patient
- Objective:
- Measurable
- Signs/Your observations
- Information from healthcare
6
Q
Assesment
A
- Justify choice of therapy
- Give reader insight into your rationale, concerns and conclusions
- Do not include new information about the patient
- Prioritize concerns to assess
7
Q
Plan
A
- Recommendations for provider(s) and patient
- Describe how the patient will be monitored
- Only disscuss what was addressed in the assesment
- Patient education
8
Q
Assesment vs. Plan
A
- Assesment:
- Why
- Sentences
- Medication class or dosage range
- Gols of therapy
- Plan:
- What
- Recommonedation
- Medication name, dose, route, frequency
- Monitoring and follow-up
9
Q
Pt appear in pain and bothered by loud noise
A
objective, PE
10
Q
BP, HR, RR
A
Objective, VS
11
Q
Denies chest pain or SOB
A
subjective, ROS
12
Q
70 years old
A
subjective, ID
13
Q
Complaining of HA
A
subjective, CC
14
Q
Pain Scale 6/10
A
subjective, HPI
15
Q
Denies fever
A
subjective, ROS
