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8 terms

SOAP notes

STUDY
PLAY
Subjective
What the patient tells you
CC and HPI, pertinent ROS to CC and HPI, Pertinent parts of the rest of history, Meds and allergy
Objective
Height, Weight, BMI, BP, T, P, R, Pain, General (well-developed, well-norished...), physical exam pertinent to the CC, lab/studies (that you have results for)
Assessments
Numbered list of diagnosis, each diagnosis has a status (acute, improving, deteriorating, chronic), working diagnosis (most probable cause of the symptoms), DDX (differential diagnosis) = 3 possible causes, other Co morbid/chronic problems
Plan
what you are going to do. Lab/xray, medications, OMM, patient education, follow-up
Chief Complaints
what the pt tells you in their own words the reason fr their visit. may use quotes.
1st line include
age, ethniticy, gender, significant PMH, CC, duration of CC
what do you write for subjective
This 43 yo Caucasian female with an unremarkable PMH presents for a follow up for cough X 14 days
only "pertinent" info
in Subject part of SOAP