SOAP notes : the down and dirty on squeaky clean documentation / Jeremiah Fleenor.
Fleenor, Jeremiah.
2007
RC65 .F54 2007 (Mapit)
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Title
SOAP notes : the down and dirty on squeaky clean documentation / Jeremiah Fleenor.
Author
Fleenor, Jeremiah.
ISBN
9780977955923 (pbk.)
Publication Details
Denver, CO : shift 4 Publishing, c2007.
Language
English
Description
xii, 62 p. : ill. ; 22 cm.
Call Number
RC65 .F54 2007
Summary
A SOAP note records an encounter with a patient. The components are Subjective (what the patient tells the recorder), Objective (what the recorder observes), Assessment (recorder's summation), Plan (recorder's actions, based on the assessment).
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Abbreviations
Gathering data quickly for the SOAP note
S and O of the SOAP note
Philosophical transition : S,O [to] A,P
General note writing settings
Tips for oral presentation and honoring clerkships
Quick reference guide.

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