Ideal SOAP Presentation on Gatorounds

The intern reviews the progress of her patient using SOAP. Subjective - symptoms Objective - vital signs, pertinent physical findings, and laboratory findings Assessment - Likely diagnosis and whether or not the patient is improving. When appropriate differential diagnosis Plan - Dx - What diagnostic tests will be ordered Rx- What medications will be initiated or maintained. Are any additional treatment modalities planned. For complex medicine patient the potential impediments to discharge or disposition problems are discussed at the end of the presentation.