global medical training @ ucla sarah kim & kevin lloyd
TRANSCRIPT
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S.O.A.PSocial and Medical Intake
Global Medical Training @ UCLASarah Kim & Kevin Lloyd
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S.O.A.P
SUBJECTIVE OBJECTIVE ASSESMENT PLAN
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SUBJECTIVE: Patient Info
First, introduce yourself!
Obtain basic info
Past medical history (PMH)
Social life Chief
complaint (secondary complaint)
Vitals (objective) Temperature Pulse Rate Blood Pressure
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SUBJECTIVE: Present Illness History of present
illness (HPI): Onset Location Duration Characteristics Aggravating factors Relieving factors Severity
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OBJECTIVE: Physical Exam
Inspection/Observation General, eyes, ears/nose/throat (ENT), cardiovascular
(CV), respiratory, gastrointestinal, muscular, skin, neurology, psychology
Auscultation Palpation Percussion
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ASSESSMENT/PLAN
Discussion of case
Assessment Preliminary
diagnosis presented to attending physicians
Plan/Treatment Prescribe medication PREVENTATIVE
ADVICE! Rx
Doctor’s prescription