Patient records
(SdotOdotAdotP)

 
 

Two options for use of patient records

 
 
patient records
 
 
patient records

Analysis notes

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Subjective assessment

Record what the patient tells you

patient assessment

Red flags red flags

Red flags are warning signs or symptoms that suggest a serious underlying disease

Please seek medical help if any of the above apply

Analysis notes

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S

S.O.A.P. notes make your assessment and treatment logical and keep your records clear.

S = Subjective; what the patient tells you i.e. symptoms you cannot see such as pain or how they are feeling, and details about family or living conditions
O = Objective; what you see (e.g. signs of infection or range of movement) and what you do (treatment given)
A = Analysis: what might be happening, e.g. show clinical reasoning
P = Plan: what you want to do next time, such as add a new treatment as patient progresses

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O

Example
for a patient with amputation

Hover over arrows for more info

READY?

When you are ready, please proceed to the assessment of your patient.

Assessment