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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.
Template to indicate and to give attribution to Creative Commons material has been copied into Wikipedia Template parameters [Edit template data] Parameter Description Type Status License type cc The Creative Commons license type Suggested values zero by1 by2 by3 by4 by3au by3cl by3pl by3us bysa2 bysa3 bysa4 Example by4 Unknown suggested URL of source URL The URL of the source page from which ...
One example is the SOAP note, where the note is organized into Subjective, Objective, Assessment, and Plan sections. Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
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CC cc: cubic centimeter (use ml instead—see the list of abbreviations used in prescriptions) chief complaint cardiac catheter carbon copy closing capacity: CCA: clear cell adenocarcinoma: CCB: calcium channel blocker: CCCU: critical coronary care unit: CCE C/C/E: clubbing, cyanosis, and edema (general signs of cardiovascular disease) CCG ...
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