Subjective

Data can come from the patient however it can also come from a family member a guardian bystanders
or other medical personnel who may be reporting to you about this patient

Chief complaint: identifying the purpose for the visit it is usually brief or concise such as headache or
nasal congestion the chief complaint could also be something like hypertension meaning the purpose of
the visit is to manage a chronic condition or to address a poorly managed chronic condition.

HPI (history of present illness): basically expands on the chief complaint here we use the mnemonic old
court which stands for onset location duration characteristics aggravating factors relieving factors and
treatment. OLD CART.

Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment

(Onset - when did this begin; Location - where on the body does this occur; Duration - when the issue
occurs; how long does it last; is it constant is it intermittent; Characteristics - How would you describe
the issue, for example if the issue is pain how painful is it on a scale of 0 to 10? Is the pain sharp or dull?
Are their associated symptoms? Aggravating factors - what makes the issue worse, for example does
movement make the pain worse? Relieving - or mitigating factors what makes the issue better?
Treatment - what did the patient do prior to the office visit to address the issue this could be in the form
of over the counter treatments or perhaps an antibiotic that was prescribed during a previous visit)

The patient's history for the purpose of this presentation history means:

The patient's current medications, allergies, medical/surgical history, social history, and family history.

All these topics are important as they can give the provider guidance on how to further assess the
patient. Sometimes medical history is revealed with the current medications for example a patient may
omit hypertension his past medical history but may list an ace inhibitor as a medication - this should
prompt the provider to confirm the patient's medical history. Family history certainly can impact patient
health as can social history all these topics must be updated for every patient visit.

Patient history is not static rather it is constantly evolving or changing for example the medication list
can certainly change - not just the medications the patient is taking but also their dosages and how they
are taken. Part of the medication history includes how it here and is the patient to their medication
regimen. Additionally, patients can certainly modify their social history both in positive and negative
manners. Again, this information is crucial in the evaluation of your patient

Subjective ROS: Once the provider gathers chief complaint, HPI, and becomes familiar with the
patient's history an appropriate and accurate review of systems must be obtained.

What is a review of systems? It is the gathering of subjective data that is organized by systems of the
body such as – respiratory, neurological, or gastrointestinal. The systems are chosen based on the
patient's chief complaint, HPI, and history.

Before proceeding to the explanation of review of systems the provider must understand the concept of
pertinent positives and pertinent negatives. These terms apply both to the subjective review of
systems and the objective physical exam.
Pertinent findings are symptoms or signs that can reasonably be expected given the patient's chief
complaint, HPI, or medical history and background.

If the finding is present, then it is a pertinent positive and if the finding is absent, then it is a pertinent
negative.

For example, a patient presenting with the chief complaint of nasal congestion may or may not have the
following signs or symptoms - cough, sore throat, fever, chills, poor appetite, or sinus pressure. These
are typical symptoms of an upper respiratory infection (URI) but that does not mean the patient will
have all of these findings.

A patient may complain of cough which would be a pertinent positive but may deny fever, which would
be a pertinent negative. Objectively, an asthmatic may or may not have wheezing. If the provider
detects wheezing upon auscultation, that would be a pertinent positive, however if the long sounds
were clear, then the provider may document no wheezing which would be a pertinent negative.

Review of systems must be appropriate and appropriately thorough.

What does this mean when I say appropriate and appropriately thorough I mean that the appropriate
systems must be chosen for review and then those systems must be appropriately reviewed.

Meaning, for a given patient you may spend a considerable amount of time reviewing one system while
only superficially reviewing another.

Again, this will be different for each patient and will be guided by the chief complaint, HPI, and history.

Let's say a 20 year old male has a simple trip and fall with an ankle injury. No syncope. The patient
simply tripped on some loose carpet and presents today with ankle pain and swelling. The provider in
this case may only need to focus on a few systems. For example the provider may want to gather
subjective data relating to the musculoskeletal system - does it hurt when the ankle is flexed; is the
patient able to ambulate? The provider may want to briefly inquire about basic neurologic findings -
such as numbness or tingling in the affected region. The provider can also ask about dermal finding such
as discoloration.

Now let's consider the patient it presents for dizziness how many systems would require investigation or
review? Looking at this list one could easily conclude that it may be easier to list the systems that do not
need to be assessed - how many systems can contribute to dizziness? Certainly cardiovascular
respiratory and neurological may seem like obvious choices, however with critical thinking other
systems may be included as well, for example significant vomiting and diarrhea that leads to
dehydration and therefore dizziness could be clarified by reviewing the gastrointestinal system; all
patients should receive a review of constitutional symptoms and then the appropriate systems following
that usually organized from head to toe.

The biggest takeaway here is that you must review all the appropriate systems all of the time. This does
not mean that all patients will have a comprehensive review or exam.

Now we are moving to objective

Please note that not all numeric information is objective - for example quantification of pain using a pain
scale is still considered subjective data.

Note that even if multiple providers seem the same objective findings those providers may draw
different conclusions

Be aware that patients can report to the provider objective information or data; for example in
discussing a rash a patient may describe how the rest presented at 1st or a patient with hypertension
may relate elevated blood pressure readings taken at home even though this is objective data it would
still belong under the subjective heading.

In the SOAP process, A stands for assessment this can be confusing to the student or new provider in
that it does not mean another review of systems or physical exam rather assessment here means
diagnosis or differential diagnoses.

Please note that we mean medical diagnoses and not nursing diagnoses.

So how does the provider develop their diagnosis or list of differential diagnoses - simply stated the
differential diagnoses are generated by combining the subjective findings plus the objective findings
from these 2 bodies of data the provider will list for most likely to least likely the potential diagnoses of
the patient complaint.

For example, the patient presents with the chief complaint of nasal congestion

Review of systems indicates rhinorrhea, cough, chills, poor appetite, and sore throat

Objective findings indicate visible nasal drainage, clear long sounds, and mildly inflamed throat without
exudate

What would the list of potential or differential diagnoses be?

The provider may consider URI, sinusitis, acute bronchitis, or pharyngitis.

These differential diagnoses were developed by combining the subjective and objective data.

Please note that if the provider rules out a differential diagnosis based on their subjective or objective
findings that diagnosis is not to be listed among the differential diagnoses.

Finally let us discuss the last component of soap. Plan. What does the plan do? The plan can gather
more data in the form of testing or referrals. These tests could include lab studies or imaging.

For example, if the provider had concern for pneumonia, they may want a chest x-ray; if there is no on
site radiology the patient may be sent for an outpatient study.

Some findings may come from a specialist, for example the provider may send a patient to cardiology for
stress testing, to pulmonology for lung function testing, or to gastroenterology for a colonoscopy, this
additional information may help to rule in or rule out a diagnosis that was listed under assessment.
Additional information attained by testing may also help clarify the type or severity of a diagnosis; for
example, a HgbA1C may be ordered to assess the status of a diabetic. Here the diagnosis is not in doubt,
but the provider needs to know the severity of the chronic condition. Certainly, the plan can help
manage or treat the diagnosis or diagnoses. This may include medications, education, and anticipatory
guidance given to the patient to help manage their symptoms and signs.

The plan is divided into 5 subheadings

Diagnostics, treatments, education, referrals, and follow up.

Not every patient will require all 5 of these components, however it is not acceptable to leave any
subheading blank.

For example, a patient may not require any diagnostics for this visit, but the provider needs to illustrate
that diagnostics were considered. Documentation may read something along the lines of “No
diagnostics or testing ordered during this visit”

Having said that all patients require education and follow up guidance, patient education and guidance
are crucial.