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CLINICAL SOAP NOTES #30 CLINICAL FACULTY:Beth Crouched, Student Name Lindsey Mueller Date 10/3/2013 Patient\'s Initials SJ DOB 11/11/1971 Reason for Visit / CC \”shortness of breath\” HP 41 yo
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Writing SOAP (Subjective, Objective, Assessment, Plan) notes involves documenting patient encounters in a structured format that includes subjective observations, objective measurements, assessments of the situation, and a plan for treatment.
Healthcare professionals, including doctors, nurses, and therapists, are required to fill out SOAP notes for each patient encounter to maintain accurate medical records.
To fill out SOAP notes, start by documenting the Subjective information (patient's own words), followed by Objective data (measurements and observations), then provide your Assessment (diagnosis), and conclude with a Plan (next steps for treatment).
The purpose of writing SOAP notes is to provide a clear and organized method to communicate patient information and track treatment progress over time.
SOAP notes must report subjective complaints, objective findings, the healthcare provider's assessment, and the treatment plan for the patient.
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