ALH 111 CH 2 SOAP

chief complaint

the main reason for the patient’s visit

history of present illness

the story of the patient’s problem

review of systems

description of individual body systems in order to discover any symptoms not directly related to the main problem

past medical history

other significant past illnesses, like high blood pressure, asthma, or diabetes

past surgical history

any of the patient’s surgeries

family history

any significant illnesses that run in the patient’s family

social history

a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health

Subjective

patients personal story of health issue

Objective

clinical findings and measurable data

Assessment

conclusion/diagnosis based on the patient records and data

Plan

course of action to address the patient's health issues and outline treatment options

What is the color for Subjective?

blue

What is the color for objective?

red

What is the color for assessment?

yellow

What is the color for plan?

green

acute

it just started recently, or is a sharp, severe symptom

chronic

it has been going on for a while now

exacerbation

it is getting worse

abrupt

all of a sudden

febrile

to have a fever

afebrile

to not have a fever

malaise

not feeling well

progressive

more and more each day

symptom

something a patient feels

noncontributory

not related to this specific problem

lethargic

a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick

genetic/hereditary

it runs in the family

alert

able to answer questions; responsive; interactive

oriented

being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is “oriented times three”

marked

it really stands out

unremarkable

another way of saying normal

auscultation

to listen

percussion

to hit something and listen to the resulting sound or feel for the resulting vibration

palpation

to feel

impression

another way of saying assessment

diagnosis

what the health care professional thinks the patient has

differential diagnosis

a list of conditions the patient may have based on the symptoms exhibited and the results of the exam

benign

safe

malignant

dangerous; a problem

degeneration

to be getting worse

remission

to get better or improve; most often used when discussing cancer; does not mean cure

idiopathic

no known specific cause; it just happens

localized

stays in a certain part of the body

systemic/generalized

all over the body (or most of it)

prognosis

the chances for things getting better or worse

occult

hidden

lesion

diseased tissue

recurrent

to have again

sequela

a problem resulting from a disease or injury

pending

waiting for

disposition

what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit

discharge

literally, to unload: 1. to send home 2. fluid coming out of a part of the body

palliative

treating the symptoms, but not actually getting rid of the cause

observation

watch, keep an eye on

reassurance

to tell the patient that the problem is not serious or dangerous

supportive care

to treat the symptoms and make the patient feel better

sterile

extremely clean, germ-free conditions

proximal

closer in to the center

distal

farther away from the center

lateral

out to the side

medial

toward the middle

ventral/antral/anterior

the front

dorsal/posterior

the back

cranial

toward the top

caudal

toward the bottom

superior

above

inferior

below

prone

lying down on belly

supine

lying down on back

contralateral

opposite side

ipsilateral

same side

unilateral

one side

bilateral

both sides

dorsum

the top of the hand or foot

plantar

the sole of the foot

palmar

the palm of the hand

sagittal

divides the body along a hypothetical plane from right to left

coronal

divides the body along a hypothetical plane from front to back

transverse

divides the body from top to bottom