16780540
| Question | Answer |
| SOAP | SOAP is an acronym for Subjective, Objective, Assessment, Plan |
| 1. Subjective Section | Owner's observations, Patient's history |
| 2. Objective Section | Veterinary professional's observation |
| 3. Assessment Section | Veterinarian's Summary of patient's problem(s) |
| 4. Plan Section | Veterinarian's plan for treatment of patient's problem |
| Patient Signalment | IDENTIFY your patient: Patient Name, Species, Breed, Age or D.O.B., Sex & Reproductive Status, Color & Markings* |
| How is patient NAME listed/noted? | “Pet’s Name” in quotations, followed by the owner’s last name |
| What is appropriate to list under the SPECIES category? | Canine, K9, or Dog Feline or Fel |
| How should an animals BREED be noted? | Universally accepted abbreviations are OK to use (Chi, Yorkie, Lab, Rott, etc) For mutts, write predominant breed name followed by “mix” or a capital “X” |
| How should an animal's sex and reproductive status be noted? | Intact male can be written as “M” Neutered male can be written as “M/N” Intact female can be written as “F” Spayed female can be written as “F/S” |
| What is important to know when listing the AGE of a patient? | Never write just a number. Always age along with weeks/months/years |
| How should an patient's COLOR and MARKINGS be listed? | Use universal colors that are understood by veterinary personnel (brown – tan, chocolate, red, liver, etc) |
| Patient History | This section is reserved for the client’s subjective observations, concerns, and requests (Subjective Section) |
| Patient history should cover these items | Chief complaint (FIRST. ALWAYS.) Any C/S/V/D Appetite, thirst, & activity level Bowels and urine output Diet Medications or supplements Vaccine history Medical history Environment & risks |
| Chief Complaint | The “reason for visit” What the patient is experiencing as a result of an undetermined problem. |
| Chief Complaint: What? | What happened? (and did someone see it happen?) What symptoms is the patient experiencing? |
| Chief Complaint: Where | Where on the body? (Which part of the body is affected) Where did the incident occur? |
| Chief Complaint: When? | When did this happen /when did this start? When do symptoms occur? (After playing, eating, drinking, etc…) |
| Chief Complaint: How? | How long has this been going on? (and has it gotten better, worse, or stayed the same?) How often does this happen? How have the patient’s normal activities been affected? |
| C/S/V/D | coughing, sneezing, vomiting, diarrhea |
| Vaccination history & status | Are Vx UTD? |
| Medical history | Past or current diseases / conditions? Any recent Sx? |
| Medications & Supplements | What is the patient taking? When was it last given? |
| Diet & Feeding Schedule | What brand / type of food? How much, how often? |
| Environment | % indoor / % outdoor Other animals in the home |
Want to create your own Flashcards for free with GoConqr? Learn more.