Professional Documents
Culture Documents
OF THE
SOAP NOTE
Subjective
Objective
Assessment
Plan
The Objective section contains the following data: VS, PE, lab results, Xray results, diagnostic test results and current medications.
and
There are two methods for the documentation of the
Assessment and Plan. The key to both is a full discussion of the differential
diagnosis of each problem (including a rationale for the differential) and
documentation of the plan and time parameters for f/u.
The first is to recap the patient in one or two sentences and then write out a
complete discussion of the differential diagnosis. Below this would be a
numbered list of each patient problem with the plan (meds, tests, labs,
counseling etc.) and f/u plan and time parameter for the follow up.
The second method lists each problem with an individual discussion
assessment and follow up plan.
REVIEW
OF THE
SOAP NOTE
S:
REVIEW
O:
HEENT:
Lungs:
Cor:
Abd:
Rectal:
Pelvic:
Extremities:
OF THE
SOAP NOTE
A:
P:
REVIEW
OF THE
SOAP NOTE
Second Style:
O:
HEENT:
Lungs:
Cor:
Abd:
Rectal:
Pelvic:
Extremities:
REVIEW
A&P:
OF THE
SOAP NOTE