The SOAP method Flashcards
S in SOAP
Subjective
O in SOAP
Objective
A in SOAP
Assessment
P in SOAP
Plan
What color is Subjective in SOAP
blue
What color is Objective in SOAP
red
What color is A in SOAP
yellow
What color is P in SOAP
green
A SOAP note is
a pattern used in writing medical notes
cause of the problem
assessment
treatment with medicine or a procedure
plan
a description of the problem in the patients own words
subjective
data collected to assist in understanding the nature of the problem
objective
the first part of the note is the
subjective part
the subjective data includes
duration of problem, quality of the problem, any exacerbating or relieving factors for that problem
the objective data includes
patient physical exam, laboratory findings, imaging studies
the assessment includes
could be diagnosis ,possible diagnosis (differential diagnosis) , identification of a problem
the plan includes
treatment with medicine, procedure. Could also consist of collecting further data to help get a more accurate diagnosis.
What is the identification of the actual problem called
diagnosis
a list of all possible causes of the patients problems or complaint
differential diagnosis
