GAUTHAM COLLEGE OF PHARMACY

A primary source of objective information (O) is the physical examination. Other relevant objective information includes laboratory values, serum drug concentrations (along with the target therapeutic range for each level), and the results of other diagnostic tests (e.g., electrocardiogram [ECG], x-rays, culture and sensitivity tests).

 

Risk factors that may predispose the patient to a particular problem should also be considered for inclusion. The communication note should include only the pertinent positive and negative findings. Pertinent negative findings are signs and symptoms of the disease or problem that are not present in the particular patient being evaluated.

 

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.

• Findings from 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.

 

Common errors:

• Scant detail is provided.

• Global summary of an intervention e.g. "ROM exercises given".