The SOAP Method ch2

Question 1

S

Answer 1

subjective: what the patient says

Question 2

O

Answer 2

objective: what the tests reveal

Question 3

A

Answer 3

assessment: the analysis of the subjective and objective information;performed by the health care provider

Question 4

P

Answer 4

plan: course of action for the patient

Question 5

Subjective

Answer 5

These are the problems that the patient states he/she has
Those problems are then translated into medical terms
This is so that you can correctly communicate the problems to all health care providers

Question 6

General subjective terms:

Answer 6

symptom
noncontributory
acute vs. chronic
abrupt
progressive vs. exacerbation
febrile vs. afebrile

Question 7

General objective terms :

Answer 7

1-Things that are seen
2-Things that are felt
3-Descriptions of what is observed
4-Things that are heard

Question 8

Things that are seen:

Answer 8

alert
oriented

Question 9

Things that are felt:

Answer 9

palpation

Question 10

Things that are heard:

Answer 10

auscultation
percussion

Question 11

Descriptions of what is observed:

Answer 11

unremarkable
marked

Question 12

General assessment terms:

Answer 12

impression
diagnosis
differential diagnosis
etiology vs. idiopathic
benign vs. malignant
remission
morbidity
mortality
prognosis
localized vs. systemic/generalized
pathogen
lesion
sequelae

Question 13

General plan terms:

Answer 13

disposition
observation
reassurance
supportive care
palliative