Question

The medical record indicates the patient's vitals Temp. 98.2, Wt. 153 BP 125/85, No acute distress, Cardio: RRR Respiratory: CTA GI: soft abdomen with normal bowel sounds, Extremities: no edema. On which part of the SOAP would this information be documented?

1) Subjective

2) History of present illness

3) Objective

4) Assessment

Answer 1

Answer is objective part.

On objective part include patient's present condition such as vital signs, physical examination details and reviwe of lab reports.

On subjective part include complaints o patient, medical and surgical health history of patient, duration of present illness and the review of system.

History of present illness is a part of subjective data.

Assessment part include the diffrential diagnosis of patient condition and current condition of patient and possible etiologies and causes are identified