(Problem-Oriented Method)

..
.

1. Problem List

/
( ), ( ),
, ,
(stable) (inactive) 1

(problem list) (medical record) , ,

, , , , (review of systems),
,

1

7 1

2. SOAP Note (subjective, objective, assessment, plan)

subjective objective data plan assessment

plan , , ,

Subjective (S)

Subjective data Subjective data

Subjective data
(review of systems; ROS) Subjective data , , ,
,

Objective (O)

Objective data , , , , ,

- (Current medications) Objective data

: 1

Assessment (A)
 subjective objective data
(systematic method) () 3

1. Etiology:
(predisposing factors)

2. Assessment if therapy is indicated: , ,

(stable) (need)

3. Assessment of current therapy and/or new therapy:

(systematically evaluate)
, ,

a. ( drug of choice) (-),

(-), , , (),
, , ,

b. , , , , ,

c. , , , , , ,

d.

e.

f.

(1) goal monitoring parameters

(2) , ,

(3)

Plan (P)

a. Therapeutic: (
assessment SOAP note) , , , , , ,

, , , ,
assessment SOAP note

b. Drugs to be avoided:
()
, , -, -, , ,
, , assessment SOAP note

c. Goals: long-term goal

subjective objective evidence
subjective objective evidence goals ,
, , , ,

d. Therapeutic and toxicity monitoring parameters:

(1) Therapeutic monitoring parameters: subjective objective data

, , (invasiveness),
, (sensitivity), subjective objective data

(end points) , ,
( goals) , ,

(alternative therapy)

(2) Toxicity monitoring parameters: , ,

subjective objective data

()

e. Patient education: , , , , , , ,
/

f. Future plans: (follow-up)

Future plans

(Case Presentation Example)

1) Boh LE (case presentation) 20-30

(handout), , ,

- (handout)

Demographic data (Dem Data) , , ,

Chief complaint (CC)

History of present illness (HPI)

Past medical history (PMH) , ,

Social history (SH)

Family history (FH)

Medications (Meds) and allergies or adverse drug reactions (ADRs)

Pertinent physical examination (PE) data

Pertinent laboratory values (Labs) creatinine clearance (Clcr)

(liver function test [LFT])

Problem List

: 5

- ,
, (prognosis)

>> :

: 5

- , , , ,
()
(therapeutic endpoints)

2. Schroeder DJ, Gourley DR, Herfindal ET

Case_______________________
Preblem___________________________________________
S:

O:

A: Etiology:

Indication for therapy:

Assessment of therapy:
 P: Therapeutic plan:

Drugs to be avoided:

Goals:

Therapeutic minitoring:

Toxicity monitoring:

Education plan:

Future plan:

(WNL= within normal limits; WDWN= well-developed, well-nourished; CNI= cranial nerves
intact)

GEN (general) COR (coronary) EXT (extremities)

VS (vital signs) - BP, RR, T, P, Wt, Ht ABD (abdomen) NEURO (neurological)
HEENT (head, eyes, ear, nose, and throat) GU (genitourinary)

1. Schroeder DJ, Gourley DR, Herfindal ET, editors. Casebook for Herfindal and Gourley's textbook of
therapeutics: disease and drug management. 6th ed. Baltimore: Williams & Wilkins; 1996.
2. Boh LE, Hanson KK. Goals, objectives, and activities. In: Boh LE, editor. Clinical clerkship manual.
Vancouver: Applied Therapeutics; 1993. p. 1-1-1-19.