the clinical record must include the time and date, your signature, and your rate or rank. SOAP Note Format SOAP stands for SUBJECTIVE, OBJECTIVE, ASSESSMENT, and PLAN. Medical documentation of patient complaint(s) and treatment must be consistent, concise, and comprehensive. The Navy Medical Department uses the SOAP note format to standardize medical evaluation entries made in clinical records. The four parts of a SOAP note are discussed below. For more detailed instructions, refer to chapter 16 of the MANMED. SUBJECTIVE.—The initial portion of the SOAP note format consists of subjective observations. These are symptoms verbally given to you by the patient or by a significant other (family or friend). These subjective observations include the patient’s descriptions of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort, or illness. OBJECTIVE.—The next part of the format is the objective observation. These objective observations include symptoms that you can actually see, hear, touch, feel, or smell. Included in objective observations are measurements such as temperature, pulse, respiration, skin color, swelling, and the results of tests. ASSESSMENT.—Assessment follows the objective observations. Assessment is the diagnosis of the patient’s condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities. PLAN.—The last part of the SOAP note is the plan. The plan may include laboratory and/or radiologic tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., binnacle list, Sick-in-Quarters (SIQ), admission to hospital), patient directions, and follow-up directions for the patient. SELF-QUESTIONING TECHNIQUES FOR PATIENT ASSESSMENT AND REPORTING Table 2-1 outlines the self-questioning techniques for patient assessment and reporting is a good guide to assist you in developing proficiency in assessing and reporting patient conditions. INPATIENT CARE A patient will often require inpatient care, whether due to injury or illness. Frequently, the inpatient will need specialized treatments, perhaps even surgery. In this part of the chapter, we will discuss the procedures for assisting both the medical inpatient and the surgical inpatient. THE MEDICAL PATIENT LEARNING OBJECTIVE: Evaluate the needs of a medical patient. For purposes of this discussion, the term medical patient applies to any person who is receiving diagnostic, therapeutic, and/or supportive care for a condition that is not managed by surgical-, orthopedic-, psychiatric-, or maternity-related therapy. This is not to infer that patients in these other categories are not treated for medical problems. Many surgical, orthopedic, psychiatric, and maternity patients do have secondary medical problems that are treated while they are undergoing management for their primary condition. Although many medical problems can be treated on an outpatient basis, this discussion will address the hospitalized medical patient. It should be noted that the basic principles of management are essentially the same for both the inpatient and outpatient. The medical management of the patient generally consists of laboratory and diagnostic tests and procedures, medication, food and fluid therapy, and patient teaching. Additionally, for many medical patients, particularly during the initial treatment phase, rest is a part of the prescribed treatment. Laboratory Tests And Diagnostic Procedures A variety of laboratory and diagnostic tests and procedures are commonly ordered for the medical patient. Frequently, the Hospital Corpsman is assigned to prepare the patient for the procedure, collect the specimens, or assist with both the procedure and specimen collection. Whether a specimen is to be collected or a procedure is to be performed, the patient needs a clear and simple explanation about what is to 2-11