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SOAP Method
[S]
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SOAP Method
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Medical Terms

Intro to Health Records

TermDefinition
SOAP Method [S] Subjective - These are the problems that the patient states they have. Those problems are then translated into medical terms.
SOAP Method [O] Objective - This is the data collected by the health care provider. This information also includes data obtained from lab tests or special images of the patient's body
SOAP Method [A] Assessment - This is a combination of the subjective and objective information.
SOAP Method [P] Plan - The plan is what the provider recommends to the patient regarding their current health status. This can include medication, surgery, and/or further tests, among other options.
General Subjective Terms [Acute vs Chronic] Acute - Just started or is a sharp, severe symptom Chronic - It's been going on for a while
General Subjective Terms [Progressive vs Exacerbation] Progressive - More and more each day Exacerbation - It is getting worse
General Objective Terms [Alert vs Oriented] Alert - Able to answer questions; responsive; interactive Oriented - Aware of 1) who he or she is, 2) where he/she is, 3) the current time
General Objective Terms [Auscultation] Auscultation - To listen
General Assessment Terms [Differential Diagnosis] Differential Diagnosis - A list of conditions the patient may have based on the symptoms exhibited and the results of the exam
General Plan Terms [Palliative] Palliative - Treating symptoms, but not getting rid of the cause
Created by: tkirkman
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