SOAP
Subjective Data.
Objective Data.
Assessment.
Plan of Action.
Subjective Data
The reason why the patient goes to the doctor. The patients chief complaints (what they feel). Patients thoughts, feelings, and perception.
Ex. Headache, nausea, and pain.
Objective Data
Visibly apparent and measurable. What you see with your own eyes.
Ex. Rash, swollen eye, vital signs.
Assessment
The physicians diagnosis or impression of the patients problem.
Strep throat, hypertension, diabetes, dehydration.
Plan (of action)
Options for treatment, the type of treatment.
Ex. Medications, bed rest, follow up.
6 C's of Charting
Clients Words.
Clarity.
Completeness.
Conciseness.
Chronological order.
Confidentiality.
Clients Words
Must be recorded accurately.
Clarity
Use medical terms and precise descriptions.
Completeness
All forms in patients chart must be completed.
Conciseness
Save time and space when recording patients information.
Chronological Order
Most recent information on top.
Confidentiality
Protect the patients privacy.