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Offering step-by-step guidance on how to properly document patient care, this updated Second Edition presents 90 of the most common clinical problems encountered on the wards and clinics in an easy-to-read, two-page layout using the familiar “SOAP” note format. Emphasizing the patient’s clinical problem, not the diagnosis, this pocket-sized quick reference teaches both clinical reasoning and documentation skills and is ideal for use by medical students, PAs, and NPs during the Family Medicine rotation.
The Introduction offers templates, tips, and guidelines for writing SOAP notes. A portable, pocket-sized format with at-a-glance, two-page layouts makes practical information quickly accessible. The SOAP approach helps students figure out where to start, while improving communication between physicians and ensuring accurate documentation.
This comprehensive guide includes:
This book is ideal for:
By mastering SOAP notes, healthcare professionals can improve their clinical reasoning and documentation skills, leading to better patient care and more accurate records.
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