- The introduction to the child
- The review of any referral information
- Recording basic observations
- Taking a history
- The physical examination
- Special investigations
- Drawing up a problem list and making a diagnosis if possible
- Planning any intervention that is needed
The letters ‘SOAP’ remind us of the 4 main steps of a general examination:
- Story (the history or subjective information)
- Observation (what you observe during the physical examination, the objective information)
- Assessment (the list of problems and diagnosis)
- Plan of action (what needs to be done)
The four main steps in the examination are the story, the observation, the assessment of the problems, and the management plan.