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Global Medical Training at UCLA
TJ & Poorva
S.O.A.P.
SUBJECTIVE
 OBJECTIVE
 ASSESSMENT
 PLAN

SUBJECTIVE: PATIENT INFO
First, introduce
yourself!
 Obtain basic info
 Past medical
history (PMH)
 Social life
 Chief complaint
(secondary
complaint)
 Vitals
(objective)

 Temperature
 Pulse Rate
 Blood Pressure
SUBJECTIVE: PRESENT ILLNESS

History of present illness (HPI):



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


Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Severity
SUBJECTIVE: Checklist of systems






Cont
Visual
Ears, Nose, Throat
Cardiology
Pulmonary
Gastrointestinal (GI)

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Endocrine
Muscular
Dermatology
Neurology
Hematology
Psychology
OBJECTIVE: PHYSICAL EXAM

Inspection/Observation



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General, eyes, ears/nose/throat (ENT), cardiovascular (CV), respiratory,
gastrointestinal, muscular, skin, neurology, psychology
Auscultation
Palpation
Percussion
ASSESSMENT/PLAN


Discussion of
case
Assessment


Preliminary diagnosis
presented to
attending physicians
Plan/Treatment

Prescribe medication
 PREVENTATIVE
ADVICE!

Rx

Doctor’s prescription