Question

The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the:__________
a. subjective.
b. objective.
c. assessment.
d. plan.
e. none of these.

Answer 1

Answer: a. Subjective

Explanation:

The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym which represents a widely used method of documentation for healthcare providers. The SOAP medical note is an organized way for healthcare workers to document.

▪Subjective : it involves the personal views or feelings of the patient, it comprises of the chief complaint, the history of the illness (when it started, for how long, its severity, its location), medical history of the patient, current medication and allergies.

▪Objective : it documents the objective data from patient encounter. It comprises of vital signs, physical exam findings, laboratory data, imaging results, recognition and review of the documentation of other clinicians.

▪Assessment : it involves assessing the patient's status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Comprises of problem and preferential diagnosis.

▪Plan : it points out the need for additional testing and consultation about the illness. It also addresses the additional steps being taken to treat the patient.