By tradition, every medical visit has a common structure.
I’m sure you recognize the basic design. You present your problem. Your doctor asks you questions about it then does a focused physical examination, makes a diagnosis and comes up with a plan for further tests or treatment.
This four-part structure is summarized in your medical records. In your family doctor’s charts, a common format for visit entries uses the acronym SOAP that stands for subjective, objective, assessment and plan.
This form of record keeping helps anyone reading the chart – for example a physician filling in for your doctor or any other health care provider you’ve authorized to give you care – to understand the thinking processes of your physician – how the diagnosis was determined and what the treatment plan is.
Familiarity with this traditional process can help you understand the pace and flow of each medical visit and as we’ll see in upcoming columns, improve communication and satisfaction in your interactions with your physicians.
When you present to your doctor a medical problem, such as abdominal pain. You might have a clear idea of what the cause might be. Though your doctor will keep your diagnosis high on the list of possible diagnoses (known as the differential diagnosis), the history, examination findings and the results of investigations will narrow the list of possible diagnoses to the most likely – and hopefully the correct – diagnosis.
Next: How your doctor “takes a history.”