Chapter 2

Front 1

SOAP stands for

Back 1

SUBJECTIVE, OBJECTIVE,
ASSESSMENT, and PLAN.

Front 2

SUBJECTIVE.

Back 2

These
are symptoms verbally given to you by the patient or by
a significant other (family or friend). These subjective
observations include the patient’s descriptions of pain
or discomfort, the presence of nausea or dizziness, and
a multitude of other descriptions of dysfunction,
discomfort, or illness.

Front 3

include symptoms that you can actually see, hear,
touch, feel, or smell. Included in objective
observations are measurements such as temperature,
pulse, respiration, skin color, swelling, and the results
of tests.

Back 3

OBJECTIVE

Front 4

is the diagnosis of
the patient’s condition.

Back 4

ASSESSMENT . In some cases the diagnosis
may be clear, such as a contusion. However, an
assessment may not be clear and could include several
diagnosis possibilities.

Front 5

PLAN

Back 5

may include laboratory and/or
radiologic tests ordered for the patient, medications
ordered, treatments performed