2-1
PART 2: CLINICAL PROCESS
Clinical Process: Medical History and Physical Examination
MAJ Andre Pennardt, MC, USA & COL Warren Whitlock, MC, USAProblem-based learning had its origin in medical education in the 1960s at McMaster University in Canada.
A method to communicate understandable, organized, and essential medical information was developed,
which later became the S-O-A-P note format of the modern problem-oriented approach to patient care^1. This
system has been so successful that it is used in all other healthcare disciplines (nursing, dentistry, pharmacy,
veterinary medicine, public health) and is taught at every medical university in the US.
The value of the SOAP format is in standardizing the collection of symptoms, organization of signs, genera-
tion of a clinical diagnosis, and formulation of a multidimensional plan. In this book, this powerful system has
been utilized for possibly the first time to organize medical information about diseases in the order in which
medics collect and report it. The goal is to make complete medical information readily available concerning
any disease or injury in the same SOAP format used by physicians, PAs, nurses and SOF medics. However,
this may the first time that specialists have organized diseases and injuries into the format that is used to
collect information, and form diagnoses and treatment plans.
- Subjective complaints
- Objective findings
- Assessment of information and development of diagnosis
- Plan of management and treatment
S-O-A-P Format CONDENSED
Subjective
Symptoms: Acute Sub acute Chronic
Constitutional
CNS
Skin
HEENT
Chest
Back
GU
Abdominal
Extremity
Hand
Foot
Other
Focused History
Objective
Signs: Acute Sub acute Chronic
Inspection (see)
Palpation (feel)
Percussion (tap)
Auscultation (listen)
Diagnostic Tests and Procedures (Essential, Recommended)