Questions: The provider orders a tonsillectomy for the patient. In which section of the SOAP note would this be recorded?
a. objective
b. assessment
c. plan
d. subjective
Transcript text: The provider orders a tonsillectomy for the patient. In which section of the SOAP note would this be recorded?
a. objective
b. assessment
c. plan
d. subjective
Solution
The answer is c. plan
Explanation
Option a: Objective
The objective section of a SOAP note includes measurable and observable data obtained during the patient examination, such as vital signs, physical examination findings, and laboratory results. It does not include treatment plans or orders.
Option b: Assessment
The assessment section contains the healthcare provider's diagnosis or clinical impression based on the subjective and objective information gathered. It summarizes the provider's evaluation of the patient's condition but does not include specific treatment orders.
Option c: Plan
The plan section outlines the proposed treatment and management strategies for the patient. This includes any orders for procedures, medications, follow-up appointments, and other interventions. A tonsillectomy order would be recorded here as it is part of the treatment plan.
Option d: Subjective
The subjective section includes information reported by the patient, such as symptoms, medical history, and the reason for the visit. It does not include the provider's orders or treatment plans.