SOAP

Four types of information documented by health care professionals 

• S- Subjective
• O- Objective
• A- Assessment
• P- Plan

Definition

What the patient states is the problem they have

Terms

Acute & Chronic             Abrupt            Febrile vs Afebrile

Malaise            Progressive vs Exacerbated    Symptom

Noncontributory           Lethargic          Genetic/Hereditary

WHAT IS THE DEFINITION AND EXAMPLES OF: OBJECTIVE?

Definition

Data collated by the healthcare provider including results of blood tests and imaging

Terms

Things SEEN: Alert, Oriented

Things HEARD: Auscultation, percussion

Things FELT: Palpation

Things OBSERVED: Unremarkable, Marked

WHAT IS THE DEFINITION AND EXAMPLES OF: ASSESSMENT?

Definition 

Combination of the subjected and objective information that leads to a diagnosis

Terms

*IMPRESSION             *DIAGNOSIS         *DEGENERATION

*DIFFERENTIAL DIAGNOSIS   *REMISSION  *RECURRENT

*BENIGN VS MALIGNANT         *ETIOLOGY VS IDIOPATHIC   

WHAT IS THE DEFINITION AND EXAMPLES OF:

PLAN? 

Definition 

What provider recommends to the patient regarding their health status. Can include medication, surgery, further tests

Terms

*DISPOSITION  *DISCHARGE  *SUPPORTIVE CARE

*PALLIATIVE *OBSERVATION *REASSURANCE *STERILE

*PROPHYLAXIS

HEALTH CARE ABBREVIATIONS

VS

VITAL SIGNS

HEALTH CARE ABBREVIATIONS

PERRLA

ALERT AND ORIENTATED

HEALTH CARE ABBREVIATIONS

NPO

nil per os

(nothing by mouth)

HEALTH CARE ABBREVIATIONS

Dx

DIAGNOSIS

HEALTH CARE ABBREVIATIONS

PRN

AS NEEDED

HEALTH CARE ABBREVIATIONS

PRN

AS NEEDED