the clinical record must include the time and date, your
signature, and your rate or rank.
SOAP Note Format
SOAP stands for SUBJECTIVE, OBJECTIVE,
ASSESSMENT, and PLAN. Medical documentation
of patient complaint(s) and treatment must be
consistent, concise, and comprehensive. The Navy
Medical Department uses the SOAP note format to
standardize medical evaluation entries made in clinical
records. The four parts of a SOAP note are discussed
below. For more detailed instructions, refer to chapter
16 of the MANMED.
SUBJECTIVE.The initial portion of the SOAP
note format consists of subjective observations. These
are symptoms verbally given to you by the patient or by
a significant other (family or friend). These subjective
observations include the patients descriptions of pain
or discomfort, the presence of nausea or dizziness, and
a multitude of other descriptions of dysfunction,
discomfort, or illness.
OBJECTIVE.The next part of the format is the
objective observation. These objective observations
include symptoms that you can actually see, hear,
touch, feel, or smell.
Included in objective
observations are measurements such as temperature,
pulse, respiration, skin color, swelling, and the results
ASSESSMENT.Assessment follows the
objective observations. Assessment is the diagnosis of
the patients condition. In some cases the diagnosis
may be clear, such as a contusion.
assessment may not be clear and could include several
PLAN.The last part of the SOAP note is the
The plan may include laboratory and/or
radiologic tests ordered for the patient, medications
ordered, treatments performed (e.g., minor surgery
procedure), patient referrals (sending patient to a
specialist), patient disposition (e.g., binnacle list,
Sick-in-Quarters (SIQ), admission to hospital), patient
directions, and follow-up directions for the patient.
FOR PATIENT ASSESSMENT AND
Table 2-1 outlines the self-questioning techniques
for patient assessment and reporting is a good guide to
assist you in developing proficiency in assessing and
reporting patient conditions.
A patient will often require inpatient care, whether
due to injury or illness. Frequently, the inpatient will
need specialized treatments, perhaps even surgery. In
this part of the chapter, we will discuss the procedures
for assisting both the medical inpatient and the surgical
THE MEDICAL PATIENT
LEARNING OBJECTIVE: Evaluate the
needs of a medical patient.
For purposes of this discussion, the term medical
patient applies to any person who is receiving
diagnostic, therapeutic, and/or supportive care for a
condition that is not managed by surgical-,
orthopedic-, psychiatric-, or maternity-related therapy.
This is not to infer that patients in these other
categories are not treated for medical problems. Many
surgical, orthopedic, psychiatric, and maternity
patients do have secondary medical problems that are
treated while they are undergoing management for
their primary condition.
Although many medical
problems can be treated on an outpatient basis, this
discussion will address the hospitalized medical
patient. It should be noted that the basic principles of
management are essentially the same for both the
inpatient and outpatient.
The medical management of the patient generally
consists of laboratory and diagnostic tests and
procedures, medication, food and fluid therapy, and
Additionally, for many medical
patients, particularly during the initial treatment phase,
rest is a part of the prescribed treatment.
Laboratory Tests And Diagnostic Procedures
A variety of laboratory and diagnostic tests and
procedures are commonly ordered for the medical
patient. Frequently, the Hospital Corpsman is assigned
to prepare the patient for the procedure, collect the
specimens, or assist with both the procedure and
specimen collection. Whether a specimen is to be
collected or a procedure is to be performed, the patient
needs a clear and simple explanation about what is to