🩺 SOAP POCKET CARD

Structured Clinical Documentation & Clinical Reasoning Tool

🔵 S — SUBJECTIVE

(What the patient tells you)

1️⃣ Chief Complaint (CC)

• “What brings you in today?”

2️⃣ History of Present Illness (HPI)

Use structure (e.g., OPQRST / OLD CARTS if relevant):

• Onset

• Provocation/Palliation

• Quality

• Radiation

• Severity

• Timing

3️⃣ Relevant Background

• PMH

• Medications

• Allergies

• Family history (if relevant)

• Social history (smoking, alcohol, occupation)

⚠️ Do NOT insert interpretation here.
Subjective = Patient narrative only.

🔴 O — OBJECTIVE

(What you observe, measure, test)

1️⃣ Vital Signs

• BP:

• HR:

• RR:

• Temp:

• SpO₂:

2️⃣ Physical Examination

• General appearance

• Targeted system exam

• Red flags

3️⃣ Investigations

• Labs:

• ECG:

• Imaging:

• Bedside tests:

⚠️ No diagnosis here.
Objective = Measurable facts only.

🟡 A — ASSESSMENT

(Clinical reasoning section — most important part)

1️⃣ Working Diagnosis

• Most likely diagnosis:

2️⃣ Differential Diagnoses

3️⃣ Justification

• Why is the leading diagnosis most likely?

• What findings support it?

• What findings argue against others?

Ask yourself:

• Does my Assessment logically follow S + O?

• What would change my mind?

🟢 P — PLAN

(What you will do about it)

1️⃣ Immediate Management

• Medications (dose + route)

• Oxygen / fluids

• Monitoring

2️⃣ Further Investigations

• Labs:

• Imaging:

• Specialist referral:

3️⃣ Disposition

• Admit / discharge / observe

• Follow-up plan

4️⃣ Patient Communication

• Explained diagnosis?

• Discussed risks?

• Informed consent?

⚠️ Avoid vague plans like “monitor patient.”
Be specific.