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12 Cards in this Set
- Front
- Back
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S in SOAP stands for |
Subjective |
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O in SOAP stands for |
Objective |
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A in SOAP stands for |
Assessment |
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P in SOAP stands for |
Plan |
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What color code is used for Subject |
Blue |
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What color code is used for Objective |
Red |
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What color is used for Assessment? |
Yellow |
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What color code is used for Plan |
Green |
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Subjective section of a health record tells: |
THE CHIEF CONCERN. The patient’s person story of the health issue. Such as main reason of the visit, description of the problem, timing, previous medical problems or surgeries, family health problems, medications/allergies. Severity, when it began, whether anything makes the problem worse. |
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Objective tells: |
The objective part of a health record tells about the data collected during the health care provider's interaction with the patient. What does the provider notice about the patient when examining the patient closely? How does the patient look, sound, feel, smell? It also includes any extra data obtained by tests done in a laboratory or by special images of the patient's body. |
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Assessment tells: |
DIAGNOSIS. Once the facts from the patient are recorded and data about the patient are collected, it is time to put it all together to reach a conclusion on the nature of the problem. This is known as the diagnosis. Sometimes one exact problem is not so obvious at first. In these cases, a health care provider may list the most likely causes, called a differential diagnosis. In addition to a diagnosis, the provider may offer other opinions, like severity of the problem and the chances for improvement. |
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Plan tells: |
In the health record, the plan lays out what the provider recommends to do about the patient's current health status. This may include medicine or home remedies, help from another health provider, surgery, or even waiting to see if the problem will improve on its own. Sometimes the plan is for more data collection to be done in the future to help figure out the true cause of the problem. |
