SOAP
Subjective, Objective, Assessment/Analysis, Plan
S: Subjective
- Patient's chief concern
- Patient's own words, actions
- Onset
- Location
- Duration
- Character
- Alleviating/Aggrevating factors
- Radiation
- Temporal pattern
- Symptoms associated
O: Objective
- Health history, vital signs, premedication
- Findings from physical examinations
- Laboratory results
- Measurements
- Dental history
- Diagnostic database
- Clinical findings
- Imaging
A: Assessment/Analysis
- Specific diagnosis
- Risk assessment
- Differential diagnosis
P: Plan
- List diagnostic, preventive, therapeutic, reevaluation indicated
- Procedures performed
- NV: Next visit