SOAP- EXAM 1
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chapter 7
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36 Terms
problem, subjective
where the patients history can be found
objective
where systems reviews can be found
objective
where tests and measures can be found
assessment
where the evaluation can be found
assessment
where the diagnosis can be found
assessment, plan
where the patient prognosis can be found
plan
where to find the interventions
problem, subjective, objective
where can information from the examination can be found?
examination
consists of history, systems review, and tests and measures
subjective information
component of the history taking portion of the examination
subjective information
data obtained from the patient
subjective information
data obtained from patients medical record
subjective information
data obtained from a patients caregiver/family
subjective information
info about patients current and past medical history
subjective information
patient symptoms and complaints
subjective information
info about factors that impact symptoms and complaints
subjective information
patients prior level of function
subjective information
patients lifestyle/occupation/societal roles
subjective information
the patients goals
objective information
component of examination process
objective information
data gathered through direct observation
objective information
gathered through methods that are reproducible
objective information
used as a reference for assessing outcomes
objective information
interventions provided
objective information
data collected during systems review
objective information
data from tests and measures
Plan
where the interventions that need to be provided are found
assessment, plan
where to find the problems that interventions are addressing
objective, assessment
where to find information about the patients current status
assessment
where to find the goals established by the PT and expected timelines for the goals
problem section
where to find the medical diagnosis
assessment
where is the PT diagnosis always found?
assessment
where the prognosis is found
problem section
where physician directed contraindications are found
assessment, plan
where precautions and contraindications can be found
problem, subjective
where patient comorbidities can be found