The SOAP note is the accepted method of medical record entries for the military. S: (subjective) - What the patient tells you.
O: (objective) - Physical findings of the exam.
A: (assessment) - Your interpretation of the patients condition. P: (plan) - Includes the following:
1. Medical treatment: includes use of meds, use of bandages, etc. 2. Additional diagnostics: which if any test which still might be needed. X-ray MRI ect.. 3. Special instructions, handouts, use of medications, side effects, etc. 4. Return to clinic: when and under what circumstances to return. Components of the SOAP note.
1. Medical History – Which gives you an idea of the patients problem before you start the physical exam of the patient. a. Patient data
b. chief complaint
1. This is the reason for the patients visit.
2. Use direct quotes from patient.
3. Avoid using medical terms.
c. Observations begin as soon as the patient walks through the door. d. Open ended questions will help you to get more complete and accurate information. e. Provider obstacles which are your attitude towards the individual or pre diagnosis of sick call ranger may prevent you from making an accurate judgment. 2. History of present illness/injury (HPI)
f. Duration: when the illness/injury started.
g. Type of pain: use the patients words to describe the type of pain. h. Location: have the patient explain, then have them point it out. i. : what makes it better or worse and is it constant or does it vary in intensity. j. Pain in different positions: does the pain vary with the change of the patients position. k. Medications/allergies: note any medications whether over the counter or not. Do the medications relate to the problem? Take note of the patients allergies. l. Supplements: note any supplements the patient is taking along with vitamins so you are aware of...
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