SOAP Notes (Med. Term.)

S

Subject; exactly what the patient says, even if provider disagrees

influenced by opinions, feelings and preferences

includes CC, Sx, HPI, PMHx, FHx, SHxO

Sx

symptoms

O

Objective; what the tests reveal, facts

includes PE, ROS, Labs, Test Results, Imaging

PE

physical exam

A

Assessment; Providers assessment of what is causing the subjective complaints and objective test results

includes Dx and DDx

Dx

Diagnosis

DDx

Differential Diagnosis; list of possible conditions that might be causing the problem

P

Plan; plan of action based on findings

includes Tx, therapy, Px, surgery, referral, consult, additional tests

Tx

treatment

Px

perscription