FOLLOW UP – SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN

After treatment begins, you need to follow how your patient improves and offer information to continue care.   You need to:    

• enquire about how they feel
• inform them about results of examinations or tests
• explain changes in their medication or care
• instruct them on any changes they need to make

For patients in hospital (in-patients), this check is done daily with each shift change during the day, or more often for sicker patients.

For patients who are not in hospital (out-patients), checks are done during each visit with the healthcare provider at a clinic or at the patient’s home.

Information that the healthcare provider records during follow-up includes:

• Subjective – what the patient has been feeling or experiencing
• Objective – what the healthcare provider finds on examination
• Assessment – summary of the patient’s current condition
• Plan – what change in care, if any, the patient should receive

Hence, sometimes these notes are called SOAP notes.

Subjective assessment – asking the patient how they feel:

General questions for any patient:

• How do you feel today?
• How are you feeling today?  (How’re you feeling today?)

For out-patients:

• How have you been since last visit? (How’ve you been since last visit?)
• How’ve you been doing (since we last spoke)?

Specific questions:

• How did you sleep last night? (How’d you sleep last night?)
• How is your appetite today?
• Is your breathing more comfortable?
• Is your arm OR leg OR stomach OR back more comfortable?
• Are your symptoms improving?
• How is your pain? (How’s your pain?)
• Does your …(hip)… still bother you?