The SOAP Note – Assessment and Plan

The SOAP Note – Assessment and Plan

The assessment and plan section of the medical SOAP note is perhaps the most important section of the SOAP note.  A well-constructed assessment and plan section usually takes the…

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The SOAP Note – One-Liner

The SOAP Note – One-Liner

The assessment and plan section of the medical soap note is perhaps the most important section of the SOAP note.  A well-constructed assessment and plan section usually takes the…

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The SOAP Note – Objective

The SOAP Note – Objective

The ideal Medical SOAP Note will contain objective information that is clear and concise. As its name implies, the objective portion of the SOAP note contains the objective data…

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The Progress Note

The Progress Note

The Progress Note Appropriately named, the progress note details the patient’s condition and how it has changed since the most recent documentation.  This note is generally brief.  Comprehensive assessment…

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Chest Pain: Lub dub and more

Chest Pain: Lub dub and more

Chest Pain: Lub dub and more This is one of the most feared chief complaints by patients and providers alike.  The differential diagnosis for this complaint includes myocardial infarction,…

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The SOAP Note – Subjective

The SOAP Note – Subjective

The SOAP Note – Subjective The structure of the SOAP note is emphasized in its name.  It stands for subjective, objective, assessment and plan.  The SOAP note format has…

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The Annual Physical

The Annual Physical

The Annual Physical Sometimes called the “wellness physical”, this encounter is a time to focus on the big picture.  It is a time to step back and consider the…

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What makes a good template

What makes a good template

Templates are meant to accomplish the tasks that are performed over and over. If you find yourself saying “I always tell patients…”, then there is probably an opportunity for a template. Obviously, there is nuance to every patient encounter. However, building templates that accommodate these nuances maximizes their efficiency. Let’s take a look at how to build a template to accommodate the nuances of medicine.

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Why we use templates

Why we use templates

Think about how you first practiced medicine. How long was your first clinic appointment? How much time did you spend writing your first medical SOAP note? You are probably a very different provider now. You are able to provide far more care in a much shorter time. How did you do this? You refined, refined and refined some more. Now you have certain tasks down to a science. You make quick work of the small tasks and simple problems. If you’re like most providers, you have used SOAP note templates to become more efficient. Let’s explore some of the concepts that make providers efficient and how using templates contributes to that efficiency.

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