What does SOAP stand for
Subjective- what you hear
Objective- what you see
Assessment- conclusion of S and O
Plan- your plan
First few steps of patient encounter
Knock
Introduce yourself
Confirm patient id
Wash hands- shake hand
Ask to sit and take notes
Subjective portion of encounter
-age
-name
-chief complaint
HPI (old carats)
ROS (review of systems
Objective portion
Vital signs (HR, respiratory rate, BP, temp…)
Physical exam- many different things
LAB findings
The assessment- neumonic to organize thoughts
I VINDICATE
Iatrogenic (iatros= doctor_
Vascular
Infectious/inflammatory
Neoplastic
Degenerative
Idiopathic
Congenital
Autoimmune
Trauma/toxins
Endocrine
Ph\sychological