quick SOAP note question

skipaway · Feb 4, 2010

where does the pt's age/race go under objective or subjective?

objective

definition of objective and subjective
objective – is a statement that is completely unbiased. it is not touched by the speaker’s previous experiences or tastes. it is verifiable by looking up facts or performing mathematical [color=#0d37cc]calculations.
subjective – is a statement that has been colored by the character of the speaker or writer. it often has a basis in reality, but reflects the perspective through with the speaker views reality. it cannot be verified using concrete facts and figures.
read more: [color=#83a7ba]difference between objective and subjective | difference between [color=#83a7ba]http://www.differencebetween.net/language/difference-between-objective-and-subjective/#ixzz0extp7wz0

mamamerlee, LPN · Feb 4, 2010

Why would age/race be in a SOAP note - they are part of demographics and/or history.

SOAP notes usually refer to the status of a diagnosis. And as noted, they are objective.

Scooter321 · Feb 6, 2010

Why would age/race be in a SOAP note - they are part of demographics and/or history.
SOAP notes usually refer to the status of a diagnosis. And as noted, they are objective.

I would have to respectfully disagree with this. SOAP notes don't just refer to the state of a diagnosis. The acronym stands for Subjective, Objective, Assessment, and Plan, and it is just one way of formatting a chart note. In my experience as a medical transcriptionist, many physicians dictate a patient's age and race as part of the SOAP/chart note, and it does indeed go in the Objective section.

Pepper The Cat, BSN, RN · Feb 6, 2010

In my experience as a medical transcriptionist, many physicians dictate a patient’s age and race as part of the SOAP/chart note, and it does indeed go in the Objective section.

I am very puzzled by something, and I hope I don't get nasty responses to this.

Why do Americans focus so much on race in the medical history.

As a Canadian, I don't think I have ever seen a medical history that mentions race. Yet every history I've seen from the USA includes race.

I am just wondering why?

Please don't flame me. I am just wondering why.

Scooter321 · Feb 6, 2010

I am very puzzled by something, and I hope I don't get nasty responses to this.
Why do Americans focus so much on race in the medical history.
As a Canadian, I don't think I have ever seen a medical history that mentions race. Yet every history I've seen from the USA includes race.
I am just wondering why?
Please don't flame me. I am just wondering why.

No flames here, but there is a valid reason for it. Many medical conditions are affected, or may be affected, by race. For instance, African Americans are more prone to hypertension, sickle cell anemia, and probably other problems. People of southern Mediterranean descent are more likely to develop thallasemia than are Caucasians. There are many more conditions and risk factors that are affected by race (I sure don't know them all). Race can be as important a part of a person's medical history as gender or age.