SOAP means Subjective, Objective, Assessment, and Plan. It is used for organizing and documenting patient information in a structured format.
- Subjective: This includes the information and observation provided by the owner such as the behavior, activity, appetite, and so on.
- Objective: This includes physical examination such as test results, x-rays, blood tests, urine tests, vital signs, etc.
- Assessment: This involves the evaluation of the doctor on the patient’s health status. It also helps identify and come up with conclusions based on information gathered.
- Plan: This involves a detailed treatment plan, medications, and follow-up care on how to treat the patient.
SOAP NOTES: This is a document containing the patient records and visits to the clinic. It can be called the Medical Record of an animal.
SOAP Notes include:
- Laboratory Test record
- Vaccination record
- Diet record
- Medication record.