the most common format is called a problem-oriented medical record
(POMR), includes general section with data from initial patient examination and assessment. Subsequent visits, the reason for those encounters are listed separately and have their own notes. SOAP notes are contained in problem-oriented medical records.
SOAP stands for: Subjective, Objective, Assessment, Plan
- ~ Subjective information is what the patient names as the problems or complaints
- ~ Objective information is what the physician finds during the exam of the patients; it may include data from laboratory tests and other procedures.
- ~Assessment, also called impression or conclusion, is the physician's diagnosis
- ~ Plan, also called advice or recommendations, is the course of treatment for the patient, such as surgery, medications, or other tests, including necessary patient monitoring, follow-up, and instructions to the patient.