SOAP NOTES WITH CORRECT DEFINITION OF TERMS

SOAP NOTES WITH CORRECT DEFINITION OF
TERMS

SOAP Note Definitions: - ✔✔1) Method of documentation used by health care providers to submit plans
in a patient's chart



2) A way to organize and present patient information in order to assess problems and find solutions



3) Identifies all of a patient's problems and ranks each problem in order of importance (How likely it is to
kill them)



4) SOAP format is used to go through every problem



SOAP Format: - ✔✔S: Subjective



O: Objective



A: Assessment



P: Plan



SOAP; Subjective - ✔✔This is what is described BY THE PATIENT in relation to the problems identified



Includes signs/symptoms and other descriptive information related to how the patient is feeling or
acting



Typically includes information about the CC (Chief Complaint):

- Onset

- If it has gotten worse or better since onset

, - Quality (sharp, dull)

- Severity (scale 1-10)

- Aggravating and remitting factors

- Treatment



IS NOT factual and cannot be reliably reproduced

- Not supported by lab values



SOAP; Subjective Information Example - ✔✔"CL is a 48 yo female presenting to the clinic complaining of
a NAGGING DRY COUGH"



"...cough STARTED ABOUT 1 week ago"



SOAP; Objective - ✔✔This is information and observations made by the healthcare provider relevant to
the patient's problem



Includes:

- Lab values

- Test results

- Physical exam results

- Vital signs




This is MEASURABLE, OBSERVABLE, and REPRODUCIBLE



SOAP; Objective Information Example: - ✔✔HTN



BP 138/88, HR 85