Intro and SOAP

The SOAP is a type of _____

Problem oriented medical record (POMR)

What does SOAP stand for?

Subjective

Objective

Assessment

Plan

What are the goals of the SOAP?

-Approach the case in a logical manner

-Work through problems systematically

-Communicate case in a thorough and concise manner

-Establish a legal record

A SOAP must be kept for a minimum of ________ years

3

What is the difference between a SOPA and a discharge?

discharges are a more formal problem oriented medical record to serves as client education and medical record

What is the difference between an academic SOAP and a clinical SOAP?

An academic SOAP is more detailed (we will utilize these in clinics)

What are some alternatives to SOAPs?

HEAP (history, exam, assessment, plan), CHOP, DAP (data, analysis, plan)

What is included in a signalment?

Breed, age, spayed/neutered, female/neutered, physical characteristics of the patient

Which section of the SOAP contains the information that you cannot put a number or rigid descriptor on, includes the signalment, complaint, history, mentation, feelings, thoughts and 'unmeasurables'?

Subjective section

Which section of the SOAP contains the information that you can put a number or rigid descriptor on, contains most of your physical exam findings, the TPR, BCS, Pain score, hydration status and the 'measurables'?

Objective section

T/F - the more accurate your subjective and objective sections are, the better your assessment and plan will be

T

Sections of the SOAP that is considered your data collection

Subjective and Objective

T/F - Subjective and Objective sections of the SOAP are often combined

A; this is because there is so much overlap in the exam

Section of the SOAP where there is analysis of the subjective and objective data and the list of problems with the differential diagnosis for each problem. In an academic SOAP, this is also where the pathophysiology and the rationale for each differential is

Assessment

VITAMIN D is an acronym to help with your differential diagnosis lists. What does this stand for?

V - Vascular

I - Inflammatory, infectious, immune mediated, iatrogenic, ischemic, idiopathic

T - Trauma, toxin

A - Allergic, anomalous, auto-immune

M - Metabolic, mechanical, mental

I - Inflammatory, infectious, immune mediated, iatrogenic, ischemic, idiopathic

N - Neoplasia, nutritional

D - Degenerative, developmental

Longest section of the SOAP that explains what you want to/are going to do and contain diagnostics and/or treatments for each problem/differential. It also contains client communication-findings, possibilities, diagnostics/treatment, prognosis, rechecks, etc.

Plan

How should you rank your differential diagnoses within the assessment section of the SOAP?

Most likely to least likely