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  2. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.

  3. OPQRST - Wikipedia

    en.wikipedia.org/wiki/OPQRST

    [3] [4] This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of a SOAP note, for later reference.

  4. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note , where the note is organized into S ubjective, O bjective, A ssessment, and P lan sections.

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  7. History of the present illness - Wikipedia

    en.wikipedia.org/wiki/History_of_the_present_illness

    Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).

  8. Past medical history - Wikipedia

    en.wikipedia.org/wiki/Past_Medical_History

    Note the date, reason, duration for the hospitalization. Injuries, or accidents: note the type and date of injury. Surgeries: note the type of procedure, date, hospital, surgeon, and any complications. Current medications: note name, dosage, frequency of any medication, including any over-the-counter medications and herbal remedies. Note ...

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    related to: examples of massage soap notes template