70 year old gentleman presenting with chest pain

Amrit Misra on May 23, 2013

This is part of a series of cases devoted to preparing incoming clincal students for life on the wards.  This particular case will focus on how to give a "SOAP" presentation on the wards.

What is it?

SOAP stands for “Subjective, Objective, Assessment, Plan” --> it is the standard way of presenting and writing progress notes in the hospital.

What are the components?

-    Subjective:  This consists of the history you obtain from the patient (so the PQRST, PMHx, PSHx, Medications, etc.)
-    Objective: This includes the patient’s vitals, physical exam findings, and relevant labs/radiology
-    Assessment:  This is a one or two line sentence that summarizes what subjective/objective parts and gives some indication of what you are thinking regarding the patient’s diagnosis/current situation.
-    Plan: This represents what you will do for the patient.  It is usually listed by problem.

This is part of a series of cases devoted to preparing incoming clincal students for life on the wards.  This particular case will focus on how to give a "SOAP" presentation on the wards.

What is it?

SOAP stands for “Subjective, Objective, Assessment, Plan” --> it is the standard way of presenting and writing progress notes in the hospital.

What are the components?

-    Subjective:  This consists of the history you obtain from the patient (so the PQRST, PMHx, PSHx, Medications, etc.)
-    Objective: This includes the patient’s vitals, physical exam findings, and relevant labs/radiology
-    Assessment:  This is a one or two line sentence that summarizes what subjective/objective parts and gives some indication of what you are thinking regarding the patient’s diagnosis/current situation.
-    Plan: This represents what you will do for the patient.  It is usually listed by problem.

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