MICROPARA LAB - Introduction to S.O.A.P Method

Lawrence L. Weed

They introduced problem-oriented medical record and clinical decision making

• Gave rise to the structure of the Subjective, Objective, Assessment, and Plan (S.O.A.P) Method

Subjective

• Chief Complaint

• History of Present Illness

• History

• Review of Systems

• Current Medications, Allergies

Chief Complaint

• Reported by the patient

• Can be a symptom, condition, previous diagnosis, or another short statement that describes why the patient is presenting today

• Similar to a title of a paper, which allows the reader to know what the rest of the document will entail

History of Present Illness

This begins with a simple one-line opening statement including the patient’s age, sex, and reason for the visit

History

• Medical History

• Surgical History

• Family History

• Social History

Review of Systems

• General

  • ex. weight loss

• Gastrointestinal

  • ex. abdominal pain

• Musculoskeletal

  • ex. toe pain

Objective

• Vital Signs

• Physical Examination Findings

• Laboratory Data

• Imaging Results

• Other Diagnostic Data

• Recognition and Review of the Documentation of Other Clinicians

Sign

An objective finding related to the associated symptom reported by the patient.

Symptom

Patient’s subjective description and should be documented under the subjective heading.

Assessment

• This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis

  • Problem (Diagnosis)

  • Differential Diagnosis

Problem (Diagnosis)

List the problem in order of importance

Differential Diagnosis

List of the different possible diagnosis, from most to least likely, and the thought process behind this list

Plan

• This section details the need for additional testing and consultation with other clinicians to address the patient’s illnesses

• Addresses any additional steps being taken to treat the patient

• Helps future physicians understand what needs to be done next