Subjective, Objective, Assessment, Planning (S.O.A.P.) Approach for Documenting Patient Data
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The identified procedure aids healthcare personnel in managing patients in a planned and organized way and is a widely used documentation methodology in modern healthcare settings. The subjective category focuses on the individual opinions and sentiments of the patient on the current disease symptoms (Podder et al., 2020). The presenting complaint, its start, location, length, nature, relieving influences, and the temporal patterns of the disease are a few examples of the data that may be used. A list of the doses and frequency of the medications used is also included, as well as the pertinent medical history of the patient. The characteristics that can be seen, measured, felt, or heard make up the patient’s collected vital signs and are included in the objective category, which describes the outcomes of the healthcare professionals’ evaluations. The results of the physical examination, laboratory information, and imaging tests are also included (Podder et al., 2020). The synthesis of the subjective and objective facts that aid in making a diagnosis is documented in the assessment section. Notably, the section may use a differential diagnosis to consider one or more diagnoses for the condition of the presenting patient. The plan, which details the precise actions to take in resolving the patient’s presenting problem, is included in the final part. It may specifically mention the need for extra tests and advice, which is significant. The necessary therapy, patient education and counseling, and specialist referrals are a few examples of plan metrics.