The essential SOAP note in an EHR age. Issue 2 (18th February 2016)

• Record Type: Journal Article
• Authors: Pearce, Patricia F.; Ferguson, Laurie Anne; George, Gwen S.; Langford, Cynthia A.
• Is Part Of: Nurse practitioner. Volume 41:Issue 2(2016:Feb.)
• Publication Date: 2016-02-18
• Subjects: documentation -- electronic health record -- history and physical exam -- SOAP note; Nursing -- Periodicals; Nurse practitioners -- Periodicals; 610.73
• DOI: 10.1097/01.NPR.0000476377.35114.d7
• Languages: English
• ISSNs: 0361-1817

Abstract

Abstract : Abstract: This article reviews the traditional Subjective, Objective, Assessment, and Plan (SOAP) note documentation format. The information in the SOAP note is useful to both providers and students for history taking and physical exam, and highlights the importance of including critical documentation details with or without an electronic health record. Abstract : This article reviews the traditional Subjective, Objective, Assessment, and Plan (SOAP) documentation format. The information is useful for both providers and students for integrating history-taking and physical exam and highlights the importance of attending to critical documentation details with or without the use of an electronic health record.