Many doctors document a patient's office visit by using the SOAP note format. This breaks down the narrative into four basic parts.
Subjective
The subjective section of the SOAP note condenses the material usually found in Chief Complaint, History of Present Illness, and Review of Systems.
Objective
The objective section of the SOAP note condenses the material usually found in Physical Examination and Laboratory Studies.
Assessment
The assessment section of the SOAP note contains the patient's diagnoses.
Plan
The plan section of the SOAP note outlines the proposed treatment options, discharge medications, and follow-up instructions given to the patient.
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