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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.
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.
Computer systems keep a log of users' access to the system. The term "log" comes from the chip log which was historically used to record distance traveled at sea and was recorded in a ship's log or logbook. To sign in connotes the same idea but is based on the analogy of manually signing a log book or visitor's book.
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