How would I apply the Subjective, Objective, Assessment, and Plan (SOAP) note framework to ambulatory care conditions for an Objective Structured Clinical Examination (OSCE)?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: April 3, 2025View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

To effectively SOAP ambulatory care conditions for an OSCE, follow a structured approach using the SOAP format (Subjective, Objective, Assessment, Plan) as outlined in the most recent and relevant study 1. This approach ensures that all critical elements of patient care are addressed, and it demonstrates clinical competence. The SOAP format is a widely accepted method for documenting patient information and creating a treatment plan. It consists of four main components:

  • Subjective: recording the patient's chief complaint, history of present illness, past medical history, medications, allergies, and social history using the patient's own words when appropriate.
  • Objective: documenting vital signs, physical examination findings, and any laboratory or diagnostic test results available.
  • Assessment: clearly stating the primary diagnosis and any differential diagnoses based on clinical reasoning.
  • Plan: creating a comprehensive plan that includes specific medications, non-pharmacological interventions, patient education points, follow-up recommendations, and any referrals needed.

During an OSCE, it is essential to verbalize your thought process as you gather information and make clinical decisions, and to practice time management to ensure completion of all sections within the allotted time 2. Maintaining a patient-centered approach by addressing the patient's concerns and preferences is also crucial 1. While studies such as 3, 4, and 5 provide valuable information on the treatment of hypertension and the use of calcium channel blockers, they are not directly relevant to the SOAP format for ambulatory care conditions in an OSCE setting. Therefore, the most recent and relevant study 1 should be prioritized when developing a SOAP approach for an OSCE. By following this structured approach, you can ensure that you are providing high-quality patient care and demonstrating your clinical competence.

References

Related Questions

What management approach is recommended for a patient with borderline hypertension and potential cardiac issues?
What is the recommended initial antihypertensive medication for a 40-year-old African-American female with newly diagnosed hypertension (elevated blood pressure), normal laboratory results, and no comorbidities such as hyperlipidemia or diabetes?
What is the next course of action for a 45-year-old female with major depressive disorder who recently increased her dose of Venlafaxine (Effexor) and developed hypertension?
What is the plan of care for an 84-year-old male patient with a history of hypertension (High Blood Pressure), gastritis, and blurred vision, taking Farxiga (Dapagliflozin) 10mg daily, Vitamin D3 50,000 units twice weekly, Pravastatin 40mg at bedtime, Vistaril (Hydroxyzine) 50mg at bedtime, Pantoprazole 40mg daily, Misoprostol 100mcg twice daily, Meloxicam 7.5mg twice daily, Metformin 500mg four times a day (QID), Lisinopril 20mg daily, Levothyroxine 50mcg daily, and Vitamin B12 1000mcg 1 tablet daily, presenting with Impaired renal function, elevated Blood Urea Nitrogen (BUN), and hyperhomocysteinemia is not mentioned but elevated Vitamin B12 levels, and inconsistent blood pressure readings?
What is the target for 24-hour ambulatory blood pressure (BP) monitoring?
What is the preferred imaging modality, Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scan, for a 29-year-old male with a suspected space-occupying lesion in the brain?
What is the optimal timing for administering insulin glargine (Lantus)?
Did I sustain a concussion from a fall on ice, given symptoms of headache and nausea?
Can laser vision correction surgery be repeated if there is a relapse of refractive error?
What is the first-line vasopressor for cardiogenic shock?
What is the dose of Lasix (Furosemide) for hypoosmolar hyponatremia?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.