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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.
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. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
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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This is the patient's description of the pain. Questions can be open ended ("Can you describe it for me?") or leading. [ 9 ] Ideally, this will elicit descriptions of the patient's pain: whether it is sharp, dull, crushing, burning, tearing, or some other feeling, along with the pattern, such as intermittent, constant, or throbbing.
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 ...
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