Subjective, Objective, Assessment, and Plan
In this course project assignment, you are presented with clinical notes for two different patients. These progress notes have been recorded as SOAP notes. A SOAP note is a common method of documenting a patient’s visit with a healthcare provider. These notes are saved in a patient’s medical record and will be used for treatment, billing, and other activities to monitor the patient’s health over time.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. Each of these components is used to record a vital part of the patient’s visit.
- Subjective: Includes the patient’s complaints and states the patient’s symptoms in his or her own words
- Objective: Includes information that the provider can measure, such as vital signs, weight, or findings from a physical exam
- Assessment: Includes a differential diagnosis or summary of signs and symptoms
- Plan: Includes treatments performed, follow-up appointment information, referrals, or other orders
You will be exploring the medical terminology used in these SOAP notes and will be asked to interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
- Download the clinical notes for the two patients:
Kay Salisbury Clinical Notes (I have attached it below)
Virginia Thompson Clinical Notes (I have attached it below)
- Download, complete, and submit the document below. This document contains questions you will answer regarding the clinical notes for each patient.
Module 02 Course Project Assignment Template (I have attached it below)
PLEASE USE A BLANK WORD DOCUMENT TO ANSWER THE QUESTIONS ON THE COURSE PROJECT QUESTIONS DOCUMENT