Purpose:  To provide a documentation of the patient’s progress during their hospital course. Obtain only that information needed to help determine the patient’s problem as quickly as possible.

Usually recorded in the medical record S.O.A.P method:

Subjective – symptoms as relayed by the patient, how has their chief complaint improved or changed.

Objective – findings (test results, physical exam…)

Assessment – of the clinical status. Begin with a statement of the patients age, past medical history and a brief summary of the patient’s current presentation/chief complaint. A statement as to the patient’s progress is appropriate, if known. Address the current diagnoses on this admission and discuss the reason the patient must stay in the hospital (further tests, monitoring, unstable, etc.)

Plan – Address the plan for tests, monitoring, and discharge. This can simply mirror the orders you write at that time.

Tags: complaints, patient assessman, patient history, patient plan, Physical Exam, symptoms

This entry was posted on Friday, July 24th, 2009 at 5:00 am and is filed under Patient Care. You can follow any responses to this entry through the RSS 2.0 feed. Responses are currently closed, but you can trackback from your own site.