CONTOH REKAM MEDIK

Dr. dr. Asri Purwanti Sp(A)K, M.Pd

Catatan Medis
• SOAP note (an acronym for subjective, objective, assessment,
and plan)
• a method of documentation employed by health care providers to
write out notes in a patient's chart, along with other common
formats, such as the admission note.
• Documenting patient encounters in the medical record is an integral
part of practice workflow starting with patient appointment
scheduling, to writing out notes, to medical billing.
• The SOAP note originated from the Problem Oriented Medical
Record (POMR), developed by Lawrence Weed, MD
• adopted as a communication tool between inter-disciplinary
healthcare providers as a way to document a patient’s progress.
SOAP notes are now commonly found in electronic medical records
(EMR) and are used by providers of various backgrounds. 
 Subjective component
• Chief Complaint, or CC. 
• History of Present Illness, or HPI. 
• In subjective information is communicated to the healthcare provider by the patient or
his/her representative. It will include all pertinent and negative symptoms under review of
body systems. Pertinent medical history, surgical history, family history, and social history,
along with current medications, smoking status, drug/alcohol/caffeine use, level of physical
activity and allergies, are also recorded. A SAMPLE history is one method of obtaining this
information from a patient.
• Subsequent visits for the same problem briefly summarize the History of Present Illness
(HPI), including pertinent testing + results, referrals, treatments, outcomes and followups.
• The mnemonic below refers to the information a physician should elicit before referring to
the patient's "old charts" or "old carts".[2]
• Onset
Location
Duration
CHaracter (sharp, dull, etc.)
Alleviating/Aggravating factors
Radiation
Temporal pattern (every morning, all day, etc.)
Severity
• Variants on this mnemonic (more than one could be listed here) include 
OPQRST and LOCQSMAT
• Location
Onset (when and mechanism of injury - if applicable)
Chronology (better or worse since onset, episodic, variable, constant, etc.)
Quality (sharp, dull, etc.)
Severity (usually a pain rating)
Modifying factors (what aggravates/reduces the symptoms - activities,
postures, drugs, etc.)
Additional symptoms (un/related or significant symptoms to the chief
complaint)
Treatment (has the patient seen another provider for this symptom?)
Anamnesis
Subjective, fundamental four.

1. RIWAYAT PENYAKIT SEKARANG:

• Keluhan utama: Sebutkan apa keluhan utamanya.
• Dari keluhan utama didalami dengan pedoman sacred seven
(location, quality, chronology/timing, severity,setting/onset,
modifying factors, associated symtoms)
• Anamnesis untuk menyingkirkan diagnosis banding penyakit
lainnya. Anamnesis itu bagaikan segitiga terbalik, banyak
ditanyakan di awal utk menyingkirkan diagnosis banding,
makin lama makin menukik ke arah penyakit yang dicurigai.
• Anamnesis terstruktur, lengkap, dan akurat.
• Harus piawai dalam interpretasi aspek yang penting dari
anamnesis.
• Pemahaman yang matang terhadap persoalan yang kompleks
 Anamnesis (subyective)
• to the information a physician should elicit before referring to the patient's "old charts" or
"old carts".[2]
• Onset
Location
Duration
CHaracter (sharp, dull, etc.)
Alleviating/Aggravating factors
Radiation
Temporal pattern (every morning, all day, etc.)
Severity
• Variants on this mnemonic (more than one could be listed here) include OPQRST and 
LOCQSMAT
• Location
Onset (when and mechanism of injury - if applicable)
Chronology (better or worse since onset, episodic, variable, constant, etc.)
Quality (sharp, dull, etc.)
Severity (usually a pain rating)
Modifying factors (what aggravates/reduces the symptoms - activities, postures, drugs, etc.)
Additional symptoms (un/related or significant symptoms to the chief complaint)
Treatment (has the patient seen another provider for this symptom?)
2. RIWAYAT PENYAKIT SEBELUMNYA, termasuk alergi terhadap
makanan/ obat-obatan
3. RIWAYAT KESEHATAN KELUARGA, tambahkan pedigree kalau
ada penyakit yang dicurigai ada kaitannya dengan faktor genetik
/ keturunan.
4. RIWAYAT PRIBADI ATAU SOSIAL PASIEN:
a. Riwayat kehamilan
b. Riwayat persalinan
c. Riwayat pasca lahir
d. Riwayat makanan
e. Riwayat tumbuh kembang
f. Riwayat imunisasi
g. Riwayat kebutuhan dasar anak (asuh, asih, asah)
h. Keadaan sosial-ekonomi keluarga, termasuk
lingkungan/tempat tinggal
 Objective Component

• observes or measures from the patient's current

presentation.
The objective component includes:
• Vital signs and measurements, such as weight.
• physical examinations, including basic systems of cardiac
and respiratory, the affected systems, possible involvement
of other systems, pertinent normal findings and
abnormalities.
• Results from laboratory and other diagnostic tests already
completed.
• Medication list obtained from pharmacy or medical
records.
Assessment
• A medical diagnosis on the given date of the note
written is a quick summary of the patient
• including a differential diagnosis,
• The assessment will also include
• progress since the last visit,
• include etiology and risk factors, assessments of the
need for therapy, current therapy, and therapy options.
• When used in a Problem Oriented Medical Record,
relevant problem numbers or headings are included as
subheadings in the assessment.
 PLAN
• will do to treat the patient's concerns - such as ordering further
labs, radiological work up, referrals given, procedures performed,
medications given and education provided.
• The plan will also include goals of therapy and patient-specific
drug and disease-state monitoring parameters.
• This should address each item of the differential diagnosis.
• For patients who have multiple health problems that are
addressed in the SOAP note, a plan is developed for each problem
and is numbered accordingly based on severity and urgency for
therapy. A note of what was discussed or advised with the patient
as well as timings for further review or follow-up are generally
included.
• Often the Assessment and Plan sections are grouped together.
• buat narasi atau tabel SOAP keadaan pasien mulai pasien
dirawat sampai dijadikan kasus, dibuat narasi yang singkat
dan jelas, jangan diulang-ulang kalau hasilnya sama, yang
ditulis kalau ada perubahan yang signifikan.
Session Structure
1. Introduction and Describing Aim &Objectives 20 min
2. Chief complaint 10min
3. History of present illness 10min

Pair Group and Role Play

4. Past medical history 10min
5. Systemic enquiry 10min
6. Family history 10min
7. Drug history 10min
8. Social history 10min
 General Approach
Introduce yourself.
• Note – never forget patient names
• Creat patient appropriately in a friendly relaxed way.
• Confidentiality and respect patient privacy.
Try to see things from patient point of view.
Understand patient underneath mental status,
anxiety, irritation or depression.
Always exhibit neutral position.

Listening
Questioning:
simple/clear/avoid medical terms/open,
leading, interrupting,
direct questions and
summarizing.
Importance of History Taking
first step
• the critical in determining the etiology of
a patient's illness
• A large percentage of the time ) 70%),

• you will actually be able make a diagnosis based on the

history alone.
How to take a history?
• The sense of what constitutes important data
will grow exponentially in future as you learn
about the pathophysiology of disease
• to obtain a good history.
• An ability to listen and ask common-sense
questions that help define the nature of a
particular problem.
• A vast and sophisticated fund of knowledge not
needed to successfully interview a patient.
Taking the history & Recording:
Always record personal details:
• name,
• age,
• address,
• sex,
• ethnicity,
• occupation,
• religion,
• marital status.
• Record date of examination
Complete History Taking
• Chief complaint
• History of present illness
• Past medical history
• Systemic enquiry
• Family history
• Drug history
• Social history
1. Anamnesis
Subjective, fundamental four.
1. RIWAYAT PENYAKIT SEKARANG:
• Keluhan utama: Chief complaint
• Sebutkan apa keluhan utamanya. Dari keluhan utama didalami
dengan pedoman sacred seven
• location,
• quality,
• chronology/timing,
• severity,setting/onset,
• modifying factors,
• associated symtoms)
• Anamnesis untuk menyingkirkan diagnosis banding penyakit lainnya.
Anamnesis itu bagaikan segitiga terbalik, banyak ditanyakan di awal
utk menyingkirkan diagnosis banding, makin lama makin menukik ke
arah penyakit yang dicurigai.
• Anamnesis terstruktur, lengkap, dan akurat.
• Harus piawai dalam interpretasi aspek yang penting dari anamnesis.
• Pemahaman yang matang terhadap persoalan yang kompleks
Chief Complaint
• THE MAIN REASON PUSH THE PT. TO SEEK FOR
VISITING a physician or for help
• Usually a SINGLE SYMPTOMS, occasionally
more than one complaints eg: chest pain,
palpitation, shortness of breath, ankle swelling
etc
• The patient DESCRIBE THE PROBLEM IN THEIR
OWN WORDS.
• It should be recorded in PT’S OWN WORDS.
• What brings your here?
• How can I help you?
• What seems to be the problem?
 Chief Complaint
Cheif Complaint (CC)
• SHORT / SPECIFIC IN ONE CLEAR SENTENCE COMMUNICATING
PRESENT / MAJOR PROBLEM / ISSUE.
• Timing – fever for last two weeks or since Monday
• Recurrent –recurring episode of abdominal pain/cough
• Any major disease important with PC e.g. DM, asthma, HT,
pregnancy, IHD:
• Note: CC should be put in patient language.
 Pain (OPQRST)
Onset of disease

Position/site

Quality, nature, character – burning sharp, stabbing, crushing; also

explain depth of pain – superficial or deep.

Relationship to anything or other bodily function/position.

Radiation: where moved to
Relieving or aggravating factors – any activities or position
Severity – how it affects daily work/physical activities. Wakes him up at
night, cannot sleep/do any work.

Timing – mode of onset (abrupt or gradual), progression (continuous or

intermittent – if intermittent ask frequency and nature.)
Treatment received or/and outcome.
Are there any associated symptoms? Check with SR.
2. RIWAYAT PENYAKIT SEBELUMNYA
History of present illness, Past medical history, Systemic enquiry
Drug history , termasuk alergi terhadap makanan/ obat-obatan

3. RIWAYAT KESEHATAN KELUARGA,

Family history, tambahkan pedigree kalau
• ada penyakit yang dicurigai ada kaitannya dengan faktor
genetik/keturunan.

4. RIWAYAT PRIBADI ATAU SOSIAL PASIEN: Social history

a) Riwayat kehamilan
b) Riwayat persalinan
c) Riwayat pasca lahir
d) Riwayat makanan
e) Riwayat tumbuh kembang
f) Riwayat imunisasi
g) Riwayat kebutuhan dasar anak (asuh, asih, asah)
h)Keadaan sosial-ekonomi keluarga, termasuk lingkungan/tempat
tinggal
Past Medical Illness
Past Medical History
• Start by asking the patient if they have any medical
problems

• IHD/Heart Attack/DM/Asthma/HT/RHD, TB/Jaundice/Fits:

E.g. if diabetic- mention time of diagnosis/current
medication/clinic check up

• Past surgical/operation history

E.g. time/place/ and what type of operation. Note any blood
transfusion and blood grouping.

• History of trauma/accidents
E.g. time/place/ and what type of accident
Drug History
Drug History (DH)
• Always use generic name or put trade name in brackets with
dosage, timing and how long. Example: Ranitidine 150 mg BD
PO
• Note: do not forget to mention OCP/Vitamins/Traditional
medicine/KAP
Drug History
• bd (Bis die) - Twice daily (usually morning and night)
• tds (ter die sumendus)/tid (ter in die) = Three times a day
mainly 8 hourly
• qds (quarter die sumendus)/qid (quarter in die) = four
times daily mainly 6 hourly
• Mane/(om – omni mane) = morning
• Nocte/(on – omni nocte) = night
• ac (ante cibum) = before food
• pc (post cibum) = after food
• po (per orum/os) = by mouth
• stat – statim = immediately as initial dose
• Rx (recipe) = treat with
Family History
• Any familial disease/running in families e.g. breast cancer,
IHD, DM,HTN schizophrenia, Developmental delay, asthma
etc.

Social History
• Smoking history - amount, duration and type. A strong
risk factor for IHD
• Drinking history - amount, duration and type. Cause
cardiomyopathy, vasodilatation
• Occupation, social and education background, ADL,
family social support and financial situation
Other Relevant History

• Gyane/Obstetric history if female

• Immunization if small child
• Note: Look for the child health card.
• Travel and sexual history if suspected STI or infectious
disease
• Note:
• If small child, obtain the history from the care giver.
Make sure; talk to right care giver.
• If some one does not talk to your language, get an
interpreter(neutral not family friend or member also
familiar with both language). Ask simple & straight
question but do not go for yes or no answer.
 System Review (SR)
This is a guide not to miss anything
Any significant finding should be moved to HPC or
PMH depending upon where you think it belongs.
Do not forget to ask associated symptoms of PC
with the System involved
When giving verbal reports, say no significant
finding on systems review to show you did it.
However when writing up patient notes, you
should record the systems review so that the
relieving doctors know what system you
covered.
 System Review
Cardiovascular
General • Chest pain
•Weakness
• Paroxysmal Nocturnal Dyspnoea
•Fatigue
• Orthopnoea
•Anorexia
• Short Of Breath(SOB)
•Change of weight
• Cough/sputum (pinkish/frank blood)
•Fever
• Swelling of ankle(SOA)
•Lumps
• Palpitations
•Night sweats
• Cyanosis

Gastrointestinal/Alimentary Respiratory System

• Appetite (anorexia/weight change) • Cough(productive/dry)
• Diet • Sputum (colour, amount, smell)
• Nausea/vomiting • Haemoptysis
• Regurgitation/heart burn/flatulence • Chest pain
• Difficulty in swallowing • SOB/Dyspnoea
• Abdominal pain/distension • Tachypnoea
• Change of bowel habit • Hoarseness
• Haematemesis, melaena, • Wheezing
haematochagia
• Jaundice
Urinary System System Review
• Frequency
• Dysuria
• Urgency
• Hesitancy Nervous System
• Terminal dribbling • Visual/Smell/Taste/Hearing/Speech
• Nocturia problem
• Back/loin pain • Head ache
• Incontinence • Fits/Faints/Black outs/loss of
• Character of urine:color/ consciousness(LOC)
amount (polyuria) & timing • Muscle
• Fever weakness/numbness/paralysis
• Abnormal sensation
Genital system • Tremor
• Pain/ discomfort/ itching • Change of behaviour or psyche
• Discharge
• Unusual bleeding
Musculoskeletal System
• Sexual history • Pain – muscle, bone, joint
• Menstrual history – menarche/ LMP/ • Swelling
duration & amount of cycle/ • Weakness/movement
Contraception • Deformities
• Obstetric history – Para/ • Gait
gravida/abortion
Health examination
Physical examination
• Physical examination is defined as a
complete assessment of a patient’s
physical and mental status.
• A physical assessment is the systematic
collection of objective information that is
directly observed or is elicited through
examination techniques
Indication of health examination
• On admission
• On discharge
• On follow up
• Health camps
• Before and after diagnostic and therapeutic procedure.
  
EQUIPMENTS

• STETHOSCOPE
• OPHTHALMOSCOPE
• OTOSCOPE
• SNELLEN CHART
• NASAL SPECULUM
• VAGINAL SPECULUM
• TUNING FORK
• PERCUSSION HARMER
• SPHYGMOMANOMETER
 POSITIONING
• Sitting/fowler’s
• STANDING
• SUPINE AND PRONE
• DORSAL RECUMBENT
• Sim’s
• LITHOTOMY
• KNEE-CHEST
PREPARING THE ENVIRONMENT
 PREPARING THE PATIENT
• PSYCHOLOGICAL PREPERATION
• PHYSICAL PREPERATION
ARTICLES REQUIRED
• Screen to provide privacy
• Bowl for antiseptic lotion
• Kidney tray and paper bag
• Weighing machine and height scale
• Patient gown
 ARTICLES REQUIRED
• Bath blanket to cover the patient

• Pair of leggings

• Draw sheet to cover patient’s chest

• Square drum containing test tube, gauze piece, cotton

swab, specimen bottle, swabsticks

• Gloves

• lubricant
 ARTICLES REQUIRED
• Torch
• Ophthalmoscope
• Snellen’s chart
• Book for colour blindness
• Pen
• Flash card
• Autoscope with speculum of different sizes
• Percussion Hammer
• Tuning fork
ARTICLES REQUIRED
• Nasal speculum
• Mouth gag
• Laryngeal mirror
• Tongue depressor
• Stethoscope
• Inch tape
ARTICLES REQUIRED
• Sterile tray for vaginal examination
• Proctoscope
• VITALS TRAY
ARTICLES FOR NEUROLOGICAL
EXAMINATION
• Powder, soap
• Snellan’s chart
• Pencil or pen
• Cotton wicks
• Torch
• Tuning fork
• Salt, sugar
ARTICLES FOR NEUROLOGICAL
EXAMINATION
• Tongue depressor
• 2 test tubes one with hot water and other with
cold water
• Safety pins
• Some thing solid for grasping
• Sharp object like key
• Reading material to assess eyes and language
of person
• Knee harmer
GENERAL SURVEY
• Identification data
• Gender and race
• Age
• Signs of distress
• Body type
• Posture
• Gait
GENERAL SURVEY
• Body movements
• Hygiene and grooming
• Body odour
• Affect and mood
• Speech
• Substance abuse:
VITALS SIGNS
HEIGHT AND WEIGHT:
ASSESSING INTEGUMENT SYSTEM
• Assessing skin
• Skin color
 Erythema
 CYANOSIS
 Jaundice
 Pallor
 Vitiligo
Inspect skin vascularity
• Ecchymosis
• Petechiae
Inspect skin lesion
Palpate skin temperature, texture,
moisture and turgor
EDEMA
PITTING EDEMA
PITTING EDEMA
• Grades of pitting edema
• Grade 0 : (none)
• Grade +1 :( trace , 2 mm)
• Disappear rapidly
• Grade +2 ( moderate , 4 mm)
• 10-15 sec
• Grade +3 (deep, 6 mm)
• ≥ 1min
• Grade +4 (very deep, 8 mm)
• 2-5min
ASSESSING NAILS
• Shape; convex
• Angle : between nail and its base is 160 degrees
• Texture: smooth, nail base should be firm and non tender
• Color: pinkish nail bed with translucent white tips
• Capillary refill
ABNORMALITIES OF NAIL
• Koilonychias (spoon nail)
• clubbing
• Paranychia
• indentations called (beau’s line)
ASSESSING HAIR AND SCALP
• color,
• texture and distribution.
• Thickness and lubrication of hair
 INSPECT THE SCALP
• Cleanliness, color, dryness,
• Lump, lesions,
• Lice (pediculus humanus capitus)
• Dandruff etc
 HEAD AND NECK
• ASSESSING THE SKULL
• for size, symmetry
• any nodules or masses
INSPECT THE FACE
ASSESS THE EYE
• Inspect external eye structure
• Position and alignment
• Exophthalmoses
• strabismus
ASSESS THE EYE
• Eye brows
• Eye lid :
• ectropion(eversion ,lid margin turn out)
• entropion(inversion, lid margin turns inwards)
• ptosis( abnormal drooping of lid over pupil
ASSESS THE EYE
• Eye lashes : sty.
• Eye balls
• Conjunctiva and sclera{ Paleness, redness or purulent,jaundice}
ASSESS THE EYE
• Cornea and iris :arcus senilis
• Pupil : PEERLA.
ACCOMMODATION
PUPILLARY REFLEX TO LIGHT
VISUAL ACUITY
INSPECT INTERNAL EYE STRUCTURES
EXTRA OCULAR
MOVEMENTS
PERIPHERAL VISION
 EARS
• AURICLES
• EAR CANAL AND TYMPANIC MEMBRANE
 HEARING
• WEBER’S TEST:
• RINNE, S TEST:
NOSE AND SINUSES
INSPECT THE MOUTH PHARYNX
AND NECK
• LIPS: lesions ,pallor (anemia), cyanosis(respiratory cardiovascular
problems), cherry colored
• BUCCAL MUCOSA , GUMS AND TEETH: teeth look for alignment ,
dental caries.buccal mucosa is a good site to visualize jaundice and
pallor.leukoplakia (thick white patches ) is a precancerous lesion.
• TONGUE
• FLOOR OF MOUTH
• PHARYNX:
 ABNORMAL FINDINGS
• pallor, cyanosis or redness
• lesions, swollen lips red tonsils, swollen red bleeding gums,
• white coating of tongue fissured tongue from dehydration.
• bright red tongue seen in deficiency of iron b12 or niacin,
• black tongue
ASSESS THE NECK
PALPATE TRACHEA AND LYMPH NODES
PALPATE THE THYROID
GLAND
 ASSESS THE THORAX AND LUNGS
• INSPECT THE THORAX
• Abnormal findings :increase in chest size and contour , abnormal
breathing pattern with the use of accessory muscles, unequal chest
expansion, and abnormal breath sounds, barrel chest, pigeon chest
PALPATE THE THORAX
PERCUSS THE THORAX
 AUSCULATE BREATH SOUND
• Bronchial sounds heard over the trachea are high – pitched, harsh
sounds with expiration longer than inspiration .
• Bronchovesicular sounds: heard over the main stem bronchus and is
moderate (blowing) sound with inspiration equal to expiration.
• Vesicular sounds are soft , low pitched and heard best in base of
lungs during inspiration longer than expiration.
ABNORMAL BREATH SOUNDS
• WHEEZE
• RHONCHI
• CRAKLES
• FRICTION RUB
CARDIO VASCULAR SYSTEM
• INSPECT NECK AND PRECORDIUM
• PALPATE THE PRECORDIUM
• AUSCULATATE HEART SOUND
AUSCULATATION
 ASSESSING THE BREAST AND AXILLA

• INSPECT BREAST AND AXILLA

• PALPATION OF BREAST AND AXILLA
ASSESSING THE ABDOMEN
QUATRANTSOFABDOMEN
INSPECT THE ABDOMEM
AUSCULTATE BOWEL
SOUNDS
PERCUSS THE ABDOMEN
PALPATE THE ABDOMEN
 ASSESS MUSCULO SKELTAL SYSTEM

• INSPECT AND PALPATE MUSCLE

 MUSCULO SKELTAL SYSTEM
• PALPATE THE BONES
• INSPECT AND PALPATE THE JOINTS
• INSPECT SPINAL CURVES
• kyphosis
• Lordosis
• Scoliosis
 ASSESSING MALE AND FEMALE GENITALIA

• INSPECT AND PALPATE FEMALE GENITALIA

INSPECT AND PALPATE RECTUM AND
ANUS
NEUROLOGICAL SYSTEM
MENTAL AND EMOTIONAL STATUS:
BEHAVIOR AND APPEARANCE
LANGUAGE
 INTELLECTUAL FUNCTION
• Memory
• Knowledge
• Abstract thinking
• Association
• Judgment
 CRANIAL NERVE FUNCTION
• Olfactory nerve (1):
• Optic nerve (2)
• Occulomotor (3)
• Trochlear (4)
• Trigeminal (5)
• Abducens (6)
 CRANIAL NERVE FUNCTION
• Facial (7)
• Auditory( 8).
• Glossopharyngeal (9)
• Vagus (10)
• Spinal accessory (11)
• Hypoglossal (12)
 MOTOR FUNCTION
• Balance and gait
• Romberg’s test
• Motor function and coordination
SENSORY FUNCTION
REFLEX FUNCTION
• Biceps reflex
• Triceps reflex
• Knee and patellar reflex
• Ankle/ Achilles tendon reflex
• Babinski reflex
• Abdominal reflex
 PERIPHERAL VASCULAR SYSTEM
ASSESSMENT
• ALLEN’S TEST
• BUERGER’S TEST
• CAPILLARY REFILL
• HOMAN’S SIGN
• PALPATE PERIPHERAL PULSES
DOCUMENTATION OF DATA
AFTER CARE OF THE PATIENT
AFTER CARE OF ARTICLES
SOAP
Subjective: how patient feels/thinks about him. How does
he look. Includes PC and general appearance/condition of
patient
Objective – relevant points of patient complaints/vital
sings, physical examination/daily weight,fluid
balance,diet/laboratory investigation and interpretation
Assessment – address each active problem after making a
problem list. Make differential diagnosis.

Plan – about management, treatment, further

investigation, follow up and rehabilitation
• The SOAP note (an acronym for subjective, objective,
assessment, and plan) is a method of documentation
employed by health care providers to write out notes in a
patient's chart, along with other common formats, such as the
admission note.
• Documenting patient encounters in the medical record is an
integral part of practice workflow starting with patient
appointment scheduling, to writing out notes, to
medical billing.
• The SOAP note originated from the Problem Oriented Medical
Record (POMR), developed by Lawrence Weed, MD.[1]
• It was initially developed for physicians, who at the time, were
the only health care providers allowed to write in a medical
record.
• Today, it is widely adopted as a communication tool between
inter-disciplinary healthcare providers as a way to document a
patient’s progress.
• SOAP notes are now commonly found in electronic medical
records (EMR) and are used by providers of various
backgrounds. Prehospital care providers such as EMTs
subjective
• Initially the patient's Chief Complaint
• History of Present Illness, or HPI.
• This describes the patient's current condition in narrative
form.
• recorded in the patient's own words.
• All information pertaining to subjective information is
communicated to the healthcare provider by the patient or
his/her representative.
• It will include all pertinent and negative symptoms under
review of body systems. Pertinent medical history, surgical
history, family history, and social
Objective
• The objective section of the SOAP includes information that
the healthcare provider observes or measures from the
patient's current presentation. The objective component
includes:
• Vital signs and measurements, such as weight.
• physical examinations, including basic systems of cardiac and
respiratory, the affected systems, possible involvement of
other systems, pertinent normal findings and abnormalities.
• Results from laboratory and other diagnostic tests already
completed.
• Medication list obtained from pharmacy or medical records.
Assessment
• A medical diagnosis
• including a differential diagnosis,
• a list of other possible diagnoses
• progress towards the patient's goal from the physician's
perspective. In a pharmacist's SOAP note,
• the assessment will identify what the drug
related/induced problem is likely to be and the
reasoning/evidence behind it.
• This will include etiology and risk factors, assessments
of the need for therapy, current therapy, and therapy
options. When used in a
Problem Oriented Medical Record, relevant problem
numbers or headings are included as subheadings in the
Plan
• to treat ordering further labs, radiological work up,
referrals given, procedures performed, medications
given and education provided
• include goals of therapy and patient-specific drug and
disease-state monitoring parameters. This should
address each item of the differential diagnosis.
• multiple health problems that are addressed in the
SOAP note, a plan is developed for each problem and is
numbered accordingly based on severity and urgency
for therapy
• Often the Assessment and Plan sections are grouped
together.
The plan itself includes various
components:
• Diagnostic component –
• continue to monitor labs
• Therapeutic component - advance diet
• Referrals –
• Follow up with Cardiology within three days of discharge for
stress testing as an out-patient.Patient education component -
that is progressing well
• Disposition component - discharge to home in the morning
The Problem
Oriented
Medical Record
(POMR or POVMR)

• Master Problem Lists

• Writing SOAP’s
• Master Plan
 The purpose of a POMR
Teaching & Learning
 Emphasize a systematic, analytic approach
 Help you learn “patterns”
 Review (learn)
 Integrate – problems & causes
 Maintain focus on the patient & his/her problems
 Student evaluation – e.g. in your clinical blocks

Communication among members of the medical team

(optimize the quality of care and minimize the potential for mistakes)

Legal Record (sign your entries!)

 Please remember
1. An “academic” SOAP is different from how you will SOAP
cases in private practice! (some different goals)

2. There is NO ONE RIGHT WAY to write a SOAP or SOAP a case.

3. There will be different expectations from different clinicians

and different clinical services. (SA Referral is our model)

4. It takes PRACTICE! (and time). Part of our goal is to give you

early exposure and some opportunity to practice.
Dr. Lawrence Weed: 1968

“Medical Records that Guide and Teach”

• Patient focused
• Problem oriented
POMR = part of an attempt to address the most common
problems in diagnosis & case management:

• Inadequate hypothesis generation

• Inattention or misinterpretation of findings
• history, PE, laboratory data, etc.

Premature closure = the clinician stops generating new

hypotheses before the correct diagnosis has been
added to the list of DfDx’s

The most common interpretive error

= overinterpretation or misinterpretation of findings in
light of suspected disease
 Why are diagnosis USUALLY correct?

Common diseases occur commonly. Duh !

Pattern recognition.
A function of experience and knowledge base.

The Challenges:
• The uncommon presentation of the common disease
• The common presentation of the uncommon disease
• The disease (common or not) that you personally have not seen before or at
least not recognized before.
Master Problem List

A PROBLEM is anything that potentially threatens the health

of the animal (or herd) and may require medical attention
(at least eventually).

MPL is always kept at the front of the record –

“front and center”
The MPL is updated DAILY
(or at each submission during a DC).
Updating & Revising MPL
Disposition of problems

• NEW problems are added

(e.g. new discoveries & new developments)

• Some problems are resolved

• Problems are re-defined
• Combined with other problems
• Upgraded to another problem
(defined at higher level of understanding)

• Problems can be inactivated

 13 year-old intact male German
Example: Shorthaired Pointer

1. Vomiting
2. Hematemesis
3. Inappetance
4. Lethargy
5. Pale mucous membranes
6. Tachypnea Upgrade to #7

7. Anemia – non-regenerative
8. Azotemia
Use slide show function &
9. Isosthenuria click to see updating MPL
(next slide)
10. Hypoproteinemia
1. Vomiting Upgrade to #11
2. Hematemesis
3. Inappetance Upgrade to #11
4. Lethargy Upgrade to #13
5. Pale mucous membranes Upgrade to #13
6. Tachypnea
Upgrade to #7
resolved 9/27
7. Anemia – non-regenerative Upgrade to #11 and/or 12
8. Azotemia
Upgrade to #12
9. Isosthenuria
10. Hypoproteinemia Upgrade to #12
Upgrade to #11
11. Gastric ulceration - endoscopy Upgrade to #13
12. Interstitial nephritis & fibrosis
(end stage kidney) – renal biopsy Upgrade to #13

13. Chronic renal failure (final Diagnosis)

Client Complaint

START
TREATMENT:
• symptomatic
• supportive
ACTIVE • presumptive
PROBLEMS
on MPL

END

Diagnosis

Specific Rx
S.O.A.P.
• Subjective:
attitude, appetite, activity, improving?, Unchanged?
- include client’s observations

• Objective:
Summarize the measurable clinical data (fever?,
laboratory?, rads?, etc.)
In the VTH, S.O. are often combined:

Problem 1. Pale mucous membranes

SO: oral mucous membranes are pale on physical

examination

Problem 2. Icterus

SO: Yellow tint to oral mucous membranes and sclera are

indicative of icterus (accumulation of bilirubin in tissues).

Problem 3. Tachypnea

SO: A respiratory rate of 44 is higher than expected of

a normal, inactive dog.
Problem 4. Diarrhea

SO: Diarrhea in this animal is chronic and appears to be progressing

(getting worse). The high volume & low frequency suggests that the
diarrhea is small intestinal in origin, as does the absence of fresh blood,
mucus, and tenesmus, which are the cardinal signs of large bowel diarrhea
in small animals.  The chronic small bowel diarrhea accompanied by
weight loss is most suggestive of a small intestinal malassimilation
syndrome, possibly with protein loss into the feces.

Problem 5. Hepatomegaly

SO: Physical examination revealed hepatomegaly characterized by

extension of the liver beyond the ribs and by rounded edges. The
hepatomegaly appears to be diffuse, but further assessment (imaging)
would be required to confirm.
S.O.A.P. – continued
 Assessment: = Analysis of the problem

3 components for each Assessment:

[A] General pathophysiologic mechanisms for the problem. (a bit of review)
[B] Pathophysiologic mechanisms likely for THIS CASE.
[C] Differential Diagnoses (DfDx's) for THIS problem.

“Rule-Outs”
Considerations:
 First: think & write about the problem by itself
 Before you think about other problems
 Before you try to think about specific DfDx’s

 Then, think and write about the problem in relation to other problems on the
MPL and other information.

e.g. Hypoproteinemia

The most common interpretive error =

overinterpretation or misinterpretation of
findings in light of suspected disease
CRITICAL THINKING & INTEGRATION

 Can you localize the disease?

(e.g. to an organ system?)
 Is the signalment important or useful? species,
breed, age, sex
 Duration & Course?
 Are other animals affected?
 Was there previous treatment / response?

 Has your understanding of the problems changed ?

- notably changed in light of new data
 How can you pull the case or problems together ?

REMEMBER: The record should capture your

THOUGHT PROCESSES
DfDx’s for the Problem:
• Localization
• Process (e.g. DAMNIT)
• Specific Diseases

One goal is to avoid:

Premature closure = the clinician stops generating new hypotheses

before the correct diagnosis has been added to the list of DfDx’s. As a
result, inappropriate Rx is initiated
 S.O.A.P. – continued
Initial PLAN – to address THIS problem.

 The plan should help rule in / rule out your primary

DfDx's, or treat the patient.

 The initial plan can include:

 specific diagnostic tests
 specific treatments
 doing nothing (wait & see)
 client communication plans (including questions)

 The proposed plan is often stated as a sequence of

plans or possible courses of actions.
 SOAP Example: Edema
a) General mechanisms
 Increased hydrostatic pressure
 Heart failure, venous obstruction, overhydration

 Decreased plasma oncotic pressure: d/t hypoalbuminemia

  albumin production d/t liver disease
  intake (malnutrition or protein malabsorption)
  protein loss
 Renal, GI, skin (wounds & burns), body cavities

 Lymphatic obstruction or hypertension (not common)

 Neoplasia, surgical or traumatic injury, lymphangitis, congenital

 Vasculitis
b) This case:
 No evidence of GI disease
 No evidence of heart disease or vasculitis
 No obvious evidence of lymphatic disease
 Good appetite
 Accompanied by weight loss
 Possible polyuria & polydipsia according to owners

c) DfDx’s:
 Protein-losing nephropathy
(e.g. glomeronephritis or renal amyloidosis)
 Loss in GI, but without producing other enteric signs such
as diarrhea (e.g. lymphangiectasia, chronic parasitism,
intestinal neoplasia)
 Chronic Liver disease – would have to be severe (>80%
loss) to produce hypoalbuminemia & edema
 Remember
IMPORTANT

– SOAPs are written daily

EACH DAY (or at each submission during a DC)

• You will SOAP all NEW problems

AND
• Re-SOAP all ACTIVE problems on your MPL

In particular, your SOAP’s of pre-existing problems should address your

updated analysis/interpretation of the problem in light of new information
and any changes in the case.
Also …..
• Make sure everyone in your DC group is sharing his/her
SOAP’s and “teaching” the others what you’ve learned.

• Otherwise, it’s like everyone has a PIECE of the puzzle, but

maybe no one has enough of the puzzle to pull it together in a
cohesive way.
Do NOT
• Just copy and paste your SOAP from one
day to the next or from one problem to
another
• “unchanged from yesterday, page 12”
• “See Problem #9”
P: Initial Plan to address this problem
Panel: WHY? - Provide a rationale!
 R/O hypoalbuminemia
 assess renal function via BUN & creatinine
 access liver enzymes as evidence of liver disease
Urinalysis:
 R/O proteinuria
 in conjunction with BUN-creatinine, assess renal function
Fecal floatation:
 R/O intestinal parasites causing protein or blood losss

Then (sequencing)

 Depending on results of minimal data base, consider future

cardiac consultation to rule out congestive heart failure (chest
rads, ECG, echocardiography, stress testing)
 Consider bile acids in future, as most sensitive measure of liver
function
 Talk to owner about a more appropriate diet
At the end of the day’s record, enter a:

Master Plan
 Panel
 Urinalysis
 Fecal Floatation
 CBC

This is a “To Do List”

= what you really want to do NOW.

Questions ?
Look at the examples you were provided
 Please remember
1. An “academic” SOAP is different from how you will SOAP
cases in private practice! (some different goals)

2. There is NO ONE RIGHT WAY to write a SOAP or SOAP a

case.

3. There will be different expectations from different

clinicians and different clinical services. (SA Referral is our
model)

4. It takes PRACTICE! (and time). Part of our goal is to give

you early exposure and some opportunity to practice.
• buat narasi atau tabel SOAP keadaan pasien mulai pasien
dirawat sampai dijadikan kasus, dibuat narasi yang singkat dan
jelas, jangan diulang-ulang kalau hasilnya sama, yang ditulis
kalau ada perubahan yang signifikan.
III. Pemeriksaan fisik
(Objective)
III. Pemeriksaan fisik (Objective) saat dijadikan kasus
• Mengidentifikasi secara benar semua tanda-tanda fisis yang
penting dari kepala sampai ujung kaki.
• Penyelesaian status yang sistematis, terstruktur dari suatu
• pemeriksaan yang kompleks. Š. Memasukkan temuan negatif
(kelainan abnormal) penting yang terkait dengan kasus
• Secara aktif mencari tanda2 “subtle” yang dapat menunjang
diagnosis
IV. Resume

• IV. Resume
• Buat resume berupa narasi yang singkat, padat, jelas yang
• mengarah ke suatu diagnosis atau diagnosis banding dan etiologi
• V. Diagnosis banding (Assessment)
• Semua diagnosis, beri dalam kurung code ICD 10 (kalau ada
kodenya)
VI. Diagnosis / diagnosis kerja
• Diagnosis kerja bisa lebih dari satu
VII. Permasalahan
• Buat daftar semua permasalahan yang ada, baik dalam
• masalah diagnosis, tatalaksana, prognosis, pencegahan, dll.
VIII. Rencana pengelolaan (Planning)
• a. Tatalaksana kegawat-daruratan (kalau ada)
• b. Rencana pemeriksaan penunjang diagnosis
• c. Rencana terapi medikamentosa
• d. Asuhan nutrisi pediatrik
• e. Rencana pemantauan
• f. Rencana rujukan, kalau diperlukan
• g. KIE
IX. Follow-up:
• Mulai dijadikan kasus sampai laporan dibuat. Buat narasi atau
• buat tabel SOAP.
X. Prognosis (Ad vitam, ad functionam, ad sanationam):
• Tulis prognosis pasien/kasus (tanpa teori). Teorinya
• didiskusikan di bab analisis.
XI. Buat skema:
• a. Skema perjalanan penyakit mulai dari awal sampai followup
• terakhir (singkat, sehingga orang akan mudah mengikuti
• perjalanan penyakit dengan melihat skema ini)
• b. Skema analisis kasus (masukkan nama jurnal dan level
• of evidence/ loe dan rekomendasinya) dari jurnal yang
• diharuskan (4 jurnal)
XII. Analisis kasus
• Š. Buat analisis kasus dengan memasukkan teori yang terkait
• dengan kasusnya, dan tulis sumber pustakanya.
• Š. Cari 4 jurnal yang bisa menjawab permasalahan (VIA,
Valid,Important, Applicable harus bagus), tidak usah
dilampirkan
• jurnal dan telaah kritisnya, cukup dituliskan: nama jurnal,
• level of evidence dan rekomendasinya. Buat kesimpulan
• singkat dari jurnal tersebut dan terapkan hasil penelusuran
• jurnal pada kasus yang anda tangani. Jangan jurnal yang
• sudah dicari tidak diterapkan pada kasus
Asesmen awal IGD
Asesment awal rawat inap
Pasien Anak
Pasien Penyakit Dalam
Pasien Bedah
Pasien Obstetri dan Ginekologi
Pasien Neurologi
Pasien THT