SOAP Notes Study Set

What does SOAP stand for?

Subjective

Objective

Assessment

Plan

What is the subjective section of a SOAP?

hx of presenting complaint and observations

What are the characteristics of the subjective section?

• signalment(species, breed, age, reproductive status)

• reported symptoms

• experiences regarding health

• history of present illness/clinical signs

What is the objective section of a SOAP?

results of a hands-on physical examination

What are the characteristics of the objective section?

• vital signs

• laboratory results

• imaging findings

• measurable data

• repeatable data

What is the assessment section of a SOAP?

the list of differential diagnoses(DDx) ranging from most likely to least likely

What are the characteristics of the assessment section?

• summary of findings

• clinical reasoning

• based on analysis

What is the plan section of a SOAP?

outlines the proposed treatment, diagnostic tests, and follow-up care for the patient based on the assessment and findings(objective)

What are the characteristics of the plan section?

• diagnostic tests (w/o results)

• treatment (medications, amounts given, and how to administer)

• client communication and education(follow-up care)

What types of questions should be asked when obtaining a medical history on an animal?

Open-ended questions; specific inquiries about symptoms, duration, and previous treatments

What types of questions should be avoided and why?

Leading questions; people are inclined to answer with a yes and may provide incorrect or biased information