@gmail.

com

S

SO
SOAP

Pronlem oriented system

SOAP

http://kensankai.lolipop.jp/index.html

http://kensankai.lolipop.jp/contents/
integrated_problem_system/practical/1.html


By problem

By problem
SOAP
SO

SOAP

Chronological

SOAP
SOAP

Chronological

SO
A
P

SOAP

Subjective

etc

Disease

Disease,EBM

(COMPLAINTs)

IllnessNBM

Review of Systems

Pertinent

Illness

Review of systems

General appearance
ABCD
Vital signs
Objective

Pertinent
Pertinent positive
Pertinent negative

Non-pertinent positiveJolt
Non-pertinent negative Kernig

Head to Toe

General appearance
A
B
RR
SpO2
CBP PR
DJCS GCS
E
BT

HEENT
Chest
Abd
Ext

Neuro.
Vasc.

Xp
CT
MRI

Problem list

0
1
2
Semantic qualifier : SQ
3

#1. 14.4.20
MCV7014.4.20
514.4.22
CF14.4.26
14.4.30
cStageT3N2M114.5.3
PS4PPS14.8.24

Brief

Assessment

SO
By problem

A
#1.
Brief summary
Probable
Less likely
Ruled out

summary

SO

3


definite
probable
possible
less likely
unlikely
ruled out

%
89
%
23

# # #1.#a.
123
abc

 Assessment

Plan
52319

Plan

Tx

Dx

Ex

Px

Air way
Breathing
Circuration
Dysfunction of CNS
Environment
Infection P&C
Insulin & Nutrition
Ion & fluid
Rest or Rehabilitation

Dx

ABG
Blood
CXR
Dextor
ECG
FAST & FEER
Gram

Tx

Dx

Ex

Px

RIME
RIME

Kolb

Reporter(
)

SO

Interpreter(
)

SOA

Manager(
)

AP

Educater(
)

12

http://www.igaku-shoin.co.jp/paperDetail.do?id=PA02985_05

C..