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SOAP

Medical notes pattern method

DefinitionTerm
Main reason for the health visit The description of the patient's problem The timing of the problem Previous medical problems or surgeries Family health Problems that might relate Current medications and allergies SUBJECTIVE
Data collected during the interaction with the patient What the provider notices about the patient during close examination Any other data obtained by tests done in a lab or by special images of the patient's body OBJECTIVE
This is where a diagnosis comes in and differential diagnosis. The provider may offer other opinions, like severity of the problem and the chances for improvement. ASSESSMENT
Lists what the provider recommends to do about the patient's current health status. could include medication, surgery, help from another provider, or waiting to see if the problem improves on its own. PLAN
closer to the center PROXIMAL
farther away from the center DISTAL
out to the side LATERAL
toward the middle MEDIAL
the front VENTRAL/ANTRAL/ANTERIOR
the back DORSAL/POSTERIOR
Created by: kendra325
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