Question

your office uses a soap format for medical records. after dr williams completes her exams explain where each of the new documents or pieces of information obtained during muhammad's exam will be filled using the soap format

Answer 1

Using soap format (an acronym for subjective, objective, assessment, and plan) is a method of documentation widely used by healthcare providers. Dr William's will fill accordingly.

Subjective: here personal views or feelings of a patient or someone close to them are recorded. This includes chief complaints, medical history, any medications, allergies etc.

Objective: here data obtained by doctor through observations by seeing, hearing, smelling and touching are recorded.

• Vital signs
• Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Recognition and review of the documentation of other clinicians.

Assessment: here the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis are recorded. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems.

Plan: here the need for additional testing and consultation with other clinicians to address the patient's illnesses are recorded. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next.