The problem description generally adopts SOAP format, that is, it is described in the order of S- patient subjective data O- objective data A- evaluation P- plan. S: The patient's main information refers to the chief complaint, symptoms, medical history and family history provided by the patient. O: Objective data refers to the patient's information, signs, laboratory examination, X-ray priority and patient's attitude and behavior observed during the doctor's diagnosis.
A: Evaluation is the most important and difficult subjective and objective information obtained by doctors through inquiry and examination in SOAP. Through comprehensive analysis, the problem is comprehensively evaluated. P: plon is a solution to patients' health problems, involving diagnosis scheme, treatment scheme, patient guidance and so on.
Medical record (problem description, course record)-in the form of-soap.
1, s: represents subjective data of patients.
Subjective information refers to subjective feelings such as complaints, symptoms, discomfort, anxiety, medical history, family history and social life history provided by patients or their medical companions. The doctor's description of the above situation stipulates that the patient's language should be used (or close to) as much as possible.
2,0: stands for objective data.
All kinds of real data obtained by observers (usually doctors) in various ways. It involves physical examination findings, physiological data, laboratory examination results, psychological and behavioral measurement results, and the attitude and behavior of patients observed by doctors.
3.a stands for health problem assessment.
Evaluation is the most important part of problem description. A complete evaluation should include diagnosis, differentiation, the severity of the problem and prognosis.
Evaluation is different from the previous disease-centered diagnosis, and its contents can be diseases, physiological problems, psychological problems and social problems. The names of symptoms of unknown factors and/or problems in chief complaint evaluation must be named according to a unified classification system. International Classification System of Primary Health Care (ICPC).
4.p: stands for the solution to the problem.
The solution to the problem embodies the patient-centered, prevention-oriented, all-round consideration of bio-psychological-social medical model, not limited to prescribing drugs. The contents of the plan should generally involve the diagnosis plan, treatment strategy (involving medication and treatment methods), education for patients, etc.