SOAP Method
This part of the SOAP note records what the patient says.
What is Subjective?
This is the term for the main reason for the patient's visit.
What is Chief Complaint?
These notes often look like clinic notes but are usually in letter format.
What are consult notes?
This plane divides the body into left and right.
What is Sagittal Plane?
This physician has special training in both evaluating causes and effects of disease and in laboratory medicine.
What is a pathologist?
This part of SOAP includes measurable data like labs or imaging.
What is Objective?
This section reviews individual body systems for symptoms not related to the main problem.
What is Review of Systems?
These summaries often group assessments and plans together.
What are admission summaries?
This plane divides the body into front and back.
What is Coronal (Frontal) Plane?
This professional assists physicians with postgraduate training under supervision.
What is a Physician Assistant?
This part of SOAP includes measurable data like labs or imaging.
What is Assessment?
This section lists illnesses in the patient’s family.
What is family history?
This record begins with the admission diagnosis and the final diagnosis.
What is a Discharge Summary or Operative Report?
This plane divides the body into top and bottom.
What is Transverse Plane?
This nurse has postgraduate training and can serve as a midlevel provider.
What is a Nurse Practitioner?
This part of SOAP describes the strategy going forward.
What is Plan?
This section includes habits like smoking, drinking, or drug use.
What is Social History?
This type of note often tracks changes day by day in the hospital.
What is a Progress Note?
Prone means lying like this.
What is lying face down (belly)?
This healthcare professional handles administrative tasks and coordinates patient care.
What is a Patient Service Coordinator?
Sometimes these two SOAP sections are grouped together.
What are Assessment and Plan?
This section of the health record indicates where the patient goes after care is completed (home, rehab, another facility).
What is disposition?
This record is just a plan written by a provider.
What is a Prescription?
Ipsilateral means this
What is same sides?
This healthcare professional has special training in pain sedation and pain control.
What is an anesthesiologist?