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Presentation on theme: "Http://moodle.devbro.com."— Presentation transcript:

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6 SOAP note (an acronym for subjective, objective, assessment, and plan)
Modified to subjective, objective, assessment of Physiology Example- Surgery Service, Dr. Jones S:No further Chest Pain or Shortness of Breath. "Feeling better today." Patient reports headache. O:Afebrile, P 84, R 16, BP 130/82. No acute distress.Neck no JVD, Lungs clearCor RRRAbd Bowel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean.Ext without edema A:Patient is a 37 year old man on post-operative day 2 for laparoscopic appendectomy. P:Recovering well. Advance diet. Continue to monitor labs. Follow-up with Cardiology within three days of discharge for stress testing as an out-patient. Prepare for discharge home tomorrow morning.

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