One of the obligations, one of the privileges that weÂ have as physicians is to teach our trade to those who come behind us. “Train up a child in the way that they should go..” so to speak as the Bible teaches. I will soon be adding a new physician in trainingÂ to my own practice. It is an added burden but it is fun teaching someone how to think through the process of determining the cause and effect of various disease states.
One of the tools that we use to do this is called the SOAP note. It includes the subjective (What symptoms does the patient complain about?), the objective (What do you see on physical examination?), the assessment (What do you conclude from your examination?), and the plan (How are you going to treat the problem?)
For example, a man comes into the office complaining about a cough and a fever of two day’s duration. That’s the subjective. He has a fever to 101 degrees, decreased breath sounds in the right half of his chest and coughs up ugly sputum right in front of you. His chest xray shows an infiltrate in the right middle lobe of his lung. That’s the objective. My assessment is that he probably has pneumonia although it could include cancer and other disease states. I have decided to treat him with oral antibiotics to see if he gets better over the next week or so. That’s my plan.
Now that sounds simple doesn’t it? Why did it take me eleven years of post graduate school to figure all that out? There must be something more to it.