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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

   The parts of the mnemonic are: Onset of the event What the patient was doing when it started (active, inactive, stressed, etc.), whether the patient believes that activity prompted the pain, [2] and whether the onset was sudden, gradual or part of an ongoing chronic problem.

4. OpenNotes - Wikipedia

   en.wikipedia.org/wiki/OpenNotes

   OpenNotes is a research initiative and international movement located at Beth Israel Deaconess Medical Center (affiliated with Harvard Medical School), that focuses on making health care more open and transparent by encouraging doctors, nurses, therapists, and other health care professionals to share clinical visit notes with patients, facilitating patients' legal right to access to their own ...

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6. 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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9. SAMPLE history - Wikipedia

   en.wikipedia.org/wiki/SAMPLE_History

   SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. [1] The SAMPLE history is sometimes used in conjunction with vital ...