I recently had a college student observe me in the office because she wants to be a pediatrician. I spent a few minutes explaining to her how a visit is organized so I thought I would also share that information with you. One of the first things a medical student learns about seeing patients and charting is "SOAP" This stands for Subjective, Objective, Assessment, and Plan. This is the order in which the visit and the charting is done.
Subjective means the information that we get from the patient. This includes history of the present illness, past medical history, family history, medications, allergies, etc. Some of this we ask every visit and some of it we review in the chart before coming into the room. It is very helpful if you voice all of your concerns and problems at this point in the visit.
Next is the objective part of the visit. This means the physical exam as well as vitals signs such as weight, temperature, blood pressure, etc.
For the next step, assessment, the doctor takes the information that she gathered in the first two steps to come up with a differential or list of what things the patient might have. Sometimes this is very easy, for example a bulging red ear drum means you have an ear infection or sometimes there are several possibilities of what you might have. I sometimes don't say a lot when I am examining a patient because I want to collect all the information and then I think while I am washing my hands before I sit down to talk with you.
The last step is the plan. Together the doctor and patient discuss treatment recommendations.
Since September the assessment and plan for all of your child's visits are available for you to view online (securely of course). The front desk has the directions on how to access this information for you.
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