Рет қаралды 38,721
The intern reviews the progress of her patient using SOAP.
Subjective - symptoms
Objective - vital signs, pertinent physical findings, and laboratory findings
Assessment - Likely diagnosis and whether or not the patient is improving. When appropriate differential diagnosis
Plan - Dx - What diagnostic tests will be ordered
Rx- What medications will be initiated or maintained. Are any
additional treatment modalities planned.
For complex medicine patient the potential impediments to discharge or disposition problems are discussed at the end of the presentation.