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SOAP note, the Glossary

The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note.^[1]

25 relations: Admission note, Appendectomy, Differential diagnosis, Electronic health record, Elsevier, Emergency department, Emergency medical technician, F. A. Davis Company, Headache, Irish Journal of Medical Science, Journal of Counseling & Development, Kaiser Permanente, Laparoscopy, Lawrence Weed, Medical billing, Medical record, OPQRST, Patient, Pearson plc, Physical examination, SAMPLE history, Signs and symptoms, SOCRATES (pain assessment), Springer Publishing, Wiley (publisher).
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Mnemonic acronyms

Admission note

An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. SOAP note and admission note are medical terminology.

See SOAP note and Admission note

Appendectomy

An appendectomy (American English) or appendicectomy (British English) is a surgical operation in which the vermiform appendix (a portion of the intestine) is removed.

See SOAP note and Appendectomy

Differential diagnosis

In healthcare, a differential diagnosis (DDx) is a method of analysis that distinguishes a particular disease or condition from others that present with similar clinical features. SOAP note and differential diagnosis are medical mnemonics and medical terminology.

See SOAP note and Differential diagnosis

Electronic health record

An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format.

See SOAP note and Electronic health record

Elsevier

Elsevier is a Dutch academic publishing company specializing in scientific, technical, and medical content.

See SOAP note and Elsevier

Emergency department

An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance.

See SOAP note and Emergency department

Emergency medical technician

An emergency medical technician (often, more simply, EMT) is a medical professional that provides emergency medical services.

See SOAP note and Emergency medical technician

F. A. Davis Company

F.A. Davis Company (F.A. Davis or Davis) is a publishing firm headquartered in Philadelphia, Pennsylvania, founded by F. A. Davis (1850–1917).

See SOAP note and F. A. Davis Company

Headache

Headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. SOAP note and Headache are medical mnemonics.

See SOAP note and Headache

Irish Journal of Medical Science

The Irish Journal of Medical Science is a quarterly peer-reviewed medical journal that was established in 1832 by Robert Kane as the Dublin Journal of Medical & Chemical Science.

See SOAP note and Irish Journal of Medical Science

Journal of Counseling & Development

The Journal of Counseling & Development is a peer-reviewed academic journal published quarterly by Wiley-Blackwell on behalf of the American Counseling Association.

See SOAP note and Journal of Counseling & Development

Kaiser Permanente

Kaiser Permanente (KP) is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield.

See SOAP note and Kaiser Permanente

Laparoscopy

Laparoscopy is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera.

See SOAP note and Laparoscopy

Lawrence Weed

Lawrence Leonard Weed (December 26, 1923 – June 3, 2017) was an American physician, researcher, educator, entrepreneur and author, who is best known for creating the problem-oriented medical record as well as one of the first electronic health records.

See SOAP note and Lawrence Weed

Medical billing

Medical billing is a payment practice within the United States healthcare system.

See SOAP note and Medical billing

Medical record

The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.

See SOAP note and Medical record

OPQRST

OPQRST is a mnemonic initialism used by medical professionals to accurately discern reasons for a patient's symptoms and history in the event of an acute illness. SOAP note and OPQRST are medical mnemonics.

See SOAP note and OPQRST

Patient

A patient is any recipient of health care services that are performed by healthcare professionals. SOAP note and patient are medical terminology.

See SOAP note and Patient

Pearson plc

Pearson plc is a multinational corporation, headquartered in the UK, focused on educational publishing and services.

See SOAP note and Pearson plc

Physical examination

In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. SOAP note and physical examination are Athletic training.

See SOAP note and Physical examination

SAMPLE history

SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. SOAP note and SAMPLE history are first aid, medical mnemonics and mnemonic acronyms.

See SOAP note and SAMPLE history

Signs and symptoms

Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition.

See SOAP note and Signs and symptoms

SOCRATES (pain assessment)

SOCRATES is a mnemonic acronym used by emergency medical services, physicians, nurses, and other health professionals to evaluate the nature of pain that a patient is experiencing. SOAP note and SOCRATES (pain assessment) are medical mnemonics and mnemonic acronyms.

See SOAP note and SOCRATES (pain assessment)

Springer Publishing

Springer Publishing Company is an American publishing company of academic journals and books, focusing on the fields of nursing, gerontology, psychology, social work, counseling, public health, and rehabilitation (neuropsychology).

See SOAP note and Springer Publishing

Wiley (publisher)

John Wiley & Sons, Inc., commonly known as Wiley, is an American multinational publishing company that focuses on academic publishing and instructional materials.

See SOAP note and Wiley (publisher)

References

[1] https://en.wikipedia.org/wiki/SOAP_note

Also known as SOAP notes, Subjective Objective Assessment Plan.