Lecture 01 Soap Note

Question 1

What are the general meanings of SOAP note?

Answer 1

S=subjective= what you learn by taking patient history
O=objective= exam including structural findings, lab, radiology data
A=assessment= what you think is going on with patient
P=plan= what you and patient agree to do about the problem (including OMT performed)

Question 2

Subjective:

Answer 2

• CC
• HPI
• PMH (other active prob)
• PSH
• Meds
• allergies
• Social/family hx
• ROS

Question 3

Objective:

Answer 3

• exam findings (full or focused)
• lab data
• radiology data

Question 4

Assessment:

Answer 4

• not always a dx

- basic description of the problem (restatement of CC)

Question 5

HPI (history or present illness)

Answer 5

-this “age/race/gender” resports…. Historical data related to CC, associated symptoms