Medical Terminology

HS111: Medical Terminology

For this discussion, you will be reviewing a patient progress note on Tana Smith. You will practice using your new medical vocabulary to create a SOAP note for a patient chart. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.

The “S” stands for subjective, which contains the signs and symptoms the patient complains about; such as “I am having severe headaches,” “I am hearing voices but do not see anyone,” or “I have pain in my back and numbness in my right leg.”

The “O” stands for objective, which contains information on what you observe, such as the vital signs: Temperature: 98.6, Pulse: 62, Respiration: 16, Weight: 155, Height 5’ 5,” Blood Pressure: 128/78. It can also be information such as: “Patient grimacing when palpating (touching) left lower quadrant of abdominal region” or “Patient gait is unsteady,” “Patient’s range of motion (ROM) in left arm is limited.” You can also document information on a urine sample obtained: “Urine is dark amber” or “blood noted, urine dipstick performed; results show trace blood and protein.”

I have included an example for your reference of documenting a SOAP note.

Example:

06/01/14: S: Pt presents with c/o (complaints of) pain in back. Pt states it is painful to urinate, and is making frequent trips to the bathroom. Pt states very little comes out and urine is dark. Pt is holding left upper lumbar region. Pt states the pain has been going on for the last 2 days. O: T: 100.9, P: 90, R: 24, W: 162, H: 5’ 9” BP: 130/90. Pt is alert and responsive x 3. Urine sample obtained. Dark amber in color, urine dipstick results: trace amounts of blood