S.O.A.PSocial and Medical Intake

Global Medical Training @ UCLASarah Kim & Kevin Lloyd

S.O.A.P

SUBJECTIVE OBJECTIVE ASSESMENT PLAN

SUBJECTIVE: Patient Info

First, introduce yourself!

Obtain basic info

Past medical history (PMH)

Social life Chief

complaint (secondary complaint)

Vitals (objective) Temperature Pulse Rate Blood Pressure

SUBJECTIVE: Present Illness History of present

illness (HPI): Onset Location Duration Characteristics Aggravating factors Relieving factors Severity

OBJECTIVE: Physical Exam

Inspection/Observation General, eyes, ears/nose/throat (ENT), cardiovascular

(CV), respiratory, gastrointestinal, muscular, skin, neurology, psychology

Auscultation Palpation Percussion

ASSESSMENT/PLAN

Discussion of case

Assessment Preliminary

diagnosis presented to attending physicians

Plan/Treatment Prescribe medication PREVENTATIVE

ADVICE! Rx

Doctor’s prescription