SOAP Notes

Question 1

what does SOAP stand for

Answer 1

Subjective
Objective
Assessment
Plan

Question 2

what does EHR stand for

Answer 2

Electronic health records

Question 3

what does EMR stand for

Answer 3

Electronic Medical Records

Question 4

what is the SOAP note written for

Answer 4

1. facilitate improved communication among all involved in caring for the patient
2. to display the assessment, problems, and plans in an organized format

Question 5

How do you write the history porton

Answer 5

narrative form

Question 6

what does S contain

Answer 6

1. symptoms expressed by patient
2. second-hand account
3. recognition of injury
4. HISTORY

Question 7

what does O contain

Answer 7

1. the facts (vitals, skin color, tests)
2. OPS of HOPS

Question 8

Assessment

Answer 8

1. one sentence
2. diagnosis of patient
3. does not have to be clear

Question 9

Plan

Answer 9

1. referals
2. follow-ups
3. what you are doing as result of diagnosis

Question 10

8 things to include in the subjection portion

Answer 10

1. onset
2. location
3. duration
4. character (dull, sharp)
5. alleviating/ aggravating factors
6. radiating
7. temporal pattern (every morning, all day)
8. symptoms associated