Most health care providers use a certain standard format, either by writing or dictating, regarding how they describe the medical issues with the patients they see. They do this primarily so that the history of your health can be recalled by those who treat you as needed. Typically, this format is called a SOAP note on a patient, which is an acronym for Subjective, Objective, Assessment, and Plan.
This protocol at times varies, but the essence of the acronym is essentially the same. An example of a typical patient visit may be best illustrated by a hypothetical patient visit by a family practice doctor, for example:
This is demographics about the patient and what the patient tells the health care provider. For example:
55 year old overweight, yet pleasant male patient, states he is experiencing chest pain of moderate discomfort. In addition, patient states he has experienced episodes of syncope and fatigue, yet not consistently.
Pt. appears to be concerned about his symptoms, and wishes to be examined to attempt to discover what may be occurring with the status of his health presently. Pt. is unmarried and unemployed presently. In addition, pt. states that he has suffered from weight gain for at least the past two decades.
Pt. typically leads what may be considered a sedentary lifestyle- regardless of advice to alter this behavior stated to this patient on previous visits with myself and other health care providers. Pt. is a pack a day smoker, with a family history of cardiovascular disease.
In addition, this patient is unmarried and appears to have a flat affect. Pt. states being a moderate alcohol drinker with 2 drinks a day, usually’.*
*This provides a history and general background on the patient that is presently being seen, along with the reason, or etiology, of why the patient chose to be seen by the provider today. Notice that the health care provider does not say things such as ‘patient has a flat affect’. This is the subjective part of the examination of a patient by a health care provider.
This is what the health care provider observes about the patient- and includes both physical appearance and non-verbal motions, perhaps.
Example: Patient has no noticeable trauma to the chest area where the patient states the pain is occurring.
Breathing is presently within normal limits. Pulse is 74 beats per minute. Upon auscultation (hearing the heartbeat with a stethoscope) nothing remarkable is detected. Presently, the patient’s blood pressure reflects stage two hypertension.
An EKG will be performed on the patient, considering the patient’s age and risk factors for cardiovascular events.
At the completion of the EKG, the EKG determines that the patient has previously experienced what is called a non q wave MI, or mild heart attack, which can eventually be treated so the patient will reduce the risk of having another episode such as this.
While not a severe emergency at this time, the patient can be treated initially now that the patient has been diagnosed as having this heart attack. The treatment now will be with various medications to relieve the discomfort the patient may be experiencing.
The doctor validates the diagnosis offered by the machine as well by reading the EKG illustration as well in the form of a paper strip created by the EKG machine.
Aspirin is given to the patient, as well as a sedative due to the anxiety of learning of this experience. Nitrogen is given to the patient under the tongue for his mild chest pain.
While now medicated, the patient’s symptoms have somewhat subsided, yet considering the patient’s risk factors for cardiovascular disease of a more severe nature, the doctor suggests that the patient gets catheterized to explore any coronary blockage that may exist around the patient’s heart, which could increase the severity of the patient’s heart attack now or in the future.
And the patient agrees to this as well after the provider explains what is occurring with the patient, and the patient understands what the provider has said to the patient. A chest x-ray is ordered as well to rule out any other cause for the chest pain that accompanies what the EKG has revealed.
Blood work is done, which includes a test called a CPK with MB bands, which indicates MI severity as well. All of the diagnostic testing that has been said will be noted by this health care provider under the P of the SOAP.
Assessment, which is the diagnosis believed the patient has upon information and belief by the health care provider- According to the results of the EKG performed on this patient, the patient has experience a non-q wave MI, that appears to have been mild in nature, is noted by the health care provider.
Plan of treatment. This is what the health care provider is going to do to treat the patient considering the evidence that shows what the patient has regarding the status of his health.
Lab work mentioned with relevant blood tests, including chemical profiles and a complete blood count to rule out other causes for the patient’s condition. Platelets in the blood as well as the patient’s cholesterol are also checked with these blood tests ordered.
A test called a Pulse Ox is also performed from the patient as well, which indicates the oxygen in the patient’s blood at this time. A consultation, or a discussion, with an interventional cardiologist is conducted by the health care provider typically over the phone.
Afterwards, the patient has been scheduled to be catheterized to rule out coronary artery blockage within next hour at the hospital nearby. Pt. is not on any chronic blood thinners or other medications, aside from the medications that were given to the patient during his visit with the provider, and the cardiologist is aware of these drugs, and the time they were administered to this patient.
Pt. is reassured about what is going to occur due to what has occurred with the patient regarding the mild heart attack. The patient appears thankful for the doctor’s help and intervention. A follow-up visit is scheduled, as the provider of this patient is now the admitting doctor. The patient will be seen again by this health care provider after the additional diagnostic testing and evaluation by the cardiologist for a follow up visit.
In future visits with this patient by the health care provider, patient will be counseled about improving his health through numerous variables and ancillary staff specializing in such variables.
What you have read is an example of what may be said or written about this hypothetical patient. Every health care provider’s patient note is different, but this one may be considered most typical for this particular disease state or medical condition. Doctors document everything for good reasons, and for your benefit as well, most importantly.