2-2
Assessment
Differential Diagnoses:
- etc.
Plan
Treatment:
Primary Alternative
Primitive Empiric
- etc.
Patient Education:
General Diet
Activity Medications
Prevention and Hygiene No Improvement/deterioration
Wound Care
Follow-up Actions:
Return evaluation
Evacuation/Consultation Criteria
Medical Examination:
The comprehensive medical examination is an organized hierarchy for all medical history and physical
findings, which constitute the major portions of the Subjective and Objective portions of the SOAP format.
These sections of the SOAP note contain all findings, including tests and laboratory studies, to provide the
basis upon which all “clinical” diagnosis is made. The final assessment of information and plan to confirm
the diagnosis of an illness or injury, begin treatment, educate the patient, and form any follow up plans is
contained in the Assessment and Plan portion of the SOAP format. Despite being simple in concept, the
SOAP problem-oriented approach is a universal standard in medical education, recording medical information,
and communicating medical information to other health care providers.
A necessary part of all medical histories is patient identifying data, including name, rank, social security
number, unit, sex, and date of birth. The medical history may be divided into four parts - the chief complaint
(CC), history of present illness (HPI), review of systems (ROS), and past, family, and or social history (PFSH).
Chief Complaint:
This consists of a concise statement describing the symptom, problem, condition, diagnosis, or other factor
that is the reason the patient is seeking treatment. It is usually stated in the patient’s own words.
History of Present Illness:
This consists of a chronological description of the patient’s illness or injury. There are 8 elements associated
with the HPI.
LOCATION: Specific area of body involved; radiation; bilateral, anterior, distal, etc.
QUALITY: Specific patterns and descriptions: dull, sharp, throbbing, stabbing, constant, intermittent,
worsening, etc.
SEVERITY: Degree of severity or intensity (scale of 1-10): “feels like when...”, severe,
mild, etc.
DURATION: Onset of problem or symptom: started 3 days ago, 1 hour ago; since yesterday; until this
morning; for about 2 months, etc.
TIMING: Indicates frequency and progression, how long it lasts, how often it occurs, etc.
CONTEXT: Setting in which it occurs: what was patient doing when signs/symptoms started; occurs
after meals, etc.
MODIFYING FACTORS: What has patient done to relieve signs/symptoms: type of medications taken,
how it relieved or made worse; rest makes it better; movement makes it worse, etc.
ASSOCIATED SIGNS AND SYMPTOMS: Other signs and symptoms patient has experienced or has
at presentation: Medic should ask direct questions (e.g., nausea/vomiting, blurred vision,
change in bowel habits, etc.).