Question

Your office uses a SOAP formal for medical records, After Dr. Williams completes her exam, explain where each of the new documents or pieces of information obtained during Mohammad's exam will be filled using the SOAP format. Step-by-step solution

Answer 1

SOAP

SUBJECTIVE DATA: It is data by the patient. It is called symptoms.Patient states that "I am tired". Or I have pain

OBJECTIVE DATA: It is sign identified by physician or nurse. It can be percieved by vital sign, physical examination , radiologic finding etc. Example BP shows 170/110mm of hg is patient has hypertensiin. Or yellowish discoloration seen in sclera of eye while inspecting patient is termed as jaundice.

ASSESSMENT: Based on subjective and objective data assessment ha to be done.

PLANNING: Planning achieved based on assessment finding. For example patient has pain. The steps for relieving pain are following:

• Divert the patient to recreational activities such as meditation, yoga and deep breathing exercise.
• Administer analgesics as per doctors order.