S.O.A.P ( Short analysis from our experience in Cuba, Venezuela, Colombia and U.S.A). Welcome to discuss this topic/Bienvenidos...

 S.O.A.P or clinical examination (Beyond the physical examination): A short analysis from our experience in Venezuela, Cuba, Colombia and the USA.  

 by: Yura Casanas (foreign MD and MSN) 

 S.O.A.P (subjective, objective, Assessment, Plan) is the written proof of the interview, physical examination, labs, and medical decisions taken  by the health provider during the encounter with the patient with or without the family. It's the most useful  and recommended  framework to clearly expose the reason for visiting the health provider office, the emergency room, the occupational health providers, and other specialists. This is also a way to chronologically narrate the patient's health situation that would be useful also for the other health professionals who will continue providing care to the patient, The S.O.A,P is considered an important legal tool to resolve sue and other judicial medical problems.The individualized assessment that include subjective information with the words and description from the patient and the objective physical examination and labs results (performed and evaluated by the health providers) are a crucial instrument for the medical and nursing education , as well as to investigate some diseases incidence, prevalence, best way to prevent and treat them, and for new and better medical innovations.    

Per our previous experience, this is a global way to record the encounter with the patient, using evidence based practice that allows the health provider to guide the interview and medical examination, although the examinations were general, or complete to a new patient. For example, when we were providing medical service in the remote areas in Venezuela (Vigia).   Many of the patients were visiting us with bone ache, fever, and an intense headache. This region has high temperatures the whole year , and the people living there collect the water in big open containers  for some days, due to the water infrastructure problems. Thus, Aedes Aegypti mosquitoes love to live there. This environmental factor guides us to ask open ended questions, and assess those patients with those symptoms, thinking about the possibility of this transmissible disease: dengue. Also, keeping in mind other frequent transmissible diseases to be ruled out and that produce similar symptoms. Then, based on that, we ordered the needed labs, such as: White Blood Cells coun (WBC)t, including platelets, Hb, Hto, erytro, IgM for dengue  that can be positive after 4 to 5 days of being infected. Also we recommended toxoplasmosis, yellow fever exams because of the presence of some positive cases in that area. The lack or expensive prices  of labs in  Venezuela, Cuba, Colombia, and other countries made one scrutinize more  information in the interview,  the physical examination,  environmental factors and less expensive labs: WBC, urine test,  X rays, EKG, and some IGM fast tests. Here, in the U.S.A we can see that the labs can be more specific, for example the MAC Elisa for the detection of dengue would be another tool to use in the discussion and recommendations for the patient treatment and prevention in the community (CDC, 2025)   

On the other hand, the S.O.A.P tells a health professional, a lawyer, or investigators how professional the health provider was in gathering the information and writing this document that include:     

The Chief Complaint,  History of Present Illness, past history, family history and review of systems (including the current medications, allergies and immunizations. The interview in general  requires professional  interview technique, and a comprehensive and holistic view to  inter-connect all the symptoms, history of the disease, description of the pain(specifying the onset, location, dimension, characteristic, associated factors, relief factors, and timing (OLDCART). If the  S.O.A.P concisely describes the social history also, would be a good guide for the decision taking process, including recommending the needed labs, keeping in mind the updated guidelines and the experience. 

Past history: should include previous conditions, past mental health disorders, obstetrical problems,smoking illicit drugs, alcohol use, preventive actions and quality of life , parental status, occupation, sleeping quality , current projects, etc. But  the interview should go beyond this, for example, a full time employee as a teacher or nurse can feel happy or stressed to the point of being sick. We have seen patients that due to the permanent negative stress, sleeping problems, negative way to see life or some situations have been with cancer or other diseases. Thus, for the comprehensive gathering of information to the patient, the  S. O.A.P should describe more the facial expression, the mental status of the patient , and environmental conditions.     

Then, Objective information that includes the physical examination from the Vital Signs,  

 To the general physical examination, and each system physical exam. Its very crucial the quality description of the patient position, gait, speech pattern, cognitive and memory conditions, and from heart to toes the head, neck, thyroids,   lymph nodes, jugular and carotids inspection, palpation and auscultation,  heart, chest and respiratory,  

Abdomen: with the different and specific maneuvers, extremities, musculoskeletal inspection, palpation, range of motion, and neurological  examination that should be performed for all new patients as the previous commented systems. 

Neurological can give one important information as patient orientation, cognitive status, speech, movements,  Cranial nervesI through XII,  Muscle strength perception, Tendon deep and superficial reflexes, mental status through different mental tests as the mental status examination, depression screening, domestic Patient in supine position with back and buttocks over a hard table or surface.  As well as, Lab results, images results, other notable data documented by previous health providers  

S.O.A.P also includes ASSESSMENT 

Main Diagnosis/Problem,  Differential Diagnoses verses Main Diagnosis/Problem

Podder, Lew, &  Ghassemzadeh (2023)  emphasize that the description of the problems should be in order of importance, and for each presumptive diagnosis, should appear a clear discussion of the differential diagnosis. 

Then the Plan, that also tells one how comprehensive and holistic is the evaluation, diagnosis and decision taking of the health provider,   that sometimes gives us information about how a multidisciplinary group works for example in a case of a patient with diagnosis of cancer with symptoms and positive signs of possible metastasis in diverse organs. This plan includes the non pharmacological, pharmacological and alternative treatment. 

The epidemiological factors, our cultural self-awareness, our energy, the latest evidence-based practices, and our perspective on the patient can either positively or negatively influence our ability to prioritize the patient and their family.

Furthermore, the absence of laboratories in countries like Cuba, Venezuela, and Colombia (based on our past experience) shows that health systems, public health, disease surveillance, and determinants of health conditions are connected to the government's genuine commitment to prioritizing human well-being.

 You are invited to discuss this topic. Estás invitado a discutir este tema.

References

1.Center for Disease Control and Prevention (2025). Serologic Test for Dengue. Retrieve from https://www.cdc.gov/dengue/hcp/diagnosis-testing/serologic-tests-for-dengue-virus.html

2. Podder V, Lew V, Ghassemzadeh S. SOAP Notes. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482263/