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Business Miscellaneous in Business . 3 months ago
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.
The SOAP note originated from the problem-oriented medical record (POMR), developed nearly 50 years ago by Lawrence Weed, MD. It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way. Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress.
SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds. Generally, SOAP notes are used as a template to guide the information that physicians add to a patient's EMR. Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various members of healthcare professionals. Many healthcare providers, ranging from physicians to behavioral healthcare professionals to veterinarians, use the SOAP note format for their patient's initial visit and to monitor progress during follow-up care.
Posted on 20 Sep 2024, this text provides information on Business related to Miscellaneous in Business. Please note that while accuracy is prioritized, the data presented might not be entirely correct or up-to-date. This information is offered for general knowledge and informational purposes only, and should not be considered as a substitute for professional advice.
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