UNDERSTANDING WHAT YOUR DOCTOR'S VISIT MEANS
When you see the doctor, what should you talk about? How do you remember what the doctor tells you? Here is a simple memory trick. All you have to do is add S-O-A-P!
S – O – A – P
Let me explain. Every doctor focuses on four main things during a patient visit involving an injury: (1) what hurts you, (2) what your exam and test results show, (3) what is most likely wrong with you, and (4) what is best treatment plan for you. You can help your doctor and yourself if you understand S – O – A – P.
BEFORE YOUR VISIT, WRITE DOWN WHAT YOU WANT TO TALK ABOUT
Then use the memory trick, S – O – A – P, to organize your visit. Here's how:
“S” stands for SUBJECTIVE
When your doctor comes into the room, the doctor usually asks “what hurts?” Help your doctor understand what has changed about your injury since the last visit. Discuss with your doctor:
- Onset. Tell the doctor about the injury event that caused your pain in the first place.
- Location. Tell the doctor where your pain is located. Be specific.
- Duration. How long have you felt this pain?
- Character. Is the pain dull, sharp, achy, etc.?
- Alleviating/Aggravating Factors. What lessens the pain? What increases it?
- Radiation. Does the pain travel?
- Temporal Pattern. Is your pain different at different times of the day or night?
- Symptoms Associated. Does certain pain seem to cause other pain or symptoms?
What we are talking about here are subjective observations. These are symptoms the patient verbally expresses or has stated to be significant. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes.
“O” stands for OBJECTIVE
Your doctor will run studies and tests that are based on objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests. Ask your doctor what these objective tests reveal about your injury. Objective tests include:
- Vital Signs.
- Findings from Physical Examinations.
- Results from Lab Tests.
“A” stands for ASSESSMENT
Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.
“P” stands for PLAN
The last part of S – O – A – P is the health care provider's plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions , and follow-up directions for the patient.
AFTER YOUR VISIT, WRITE DOWN WHAT YOUR DOCTOR TOLD YOU AND CALL YOUR LAWYER WITH THIS INFORMATION SO VITAL TO YOUR CASE.