SOAP note SOAP note is a widely used documentation format in healthcare. It stands for Subjective, Objective, Assessment, and Plan. It is a structured way of organizing patient information, including their symptoms, physical findings, diagnosis, and treatment plan. ... [مشاهده متن کامل]
یادداشت SOAP یک فرمت اسنادی است که به طور گسترده در مراقبت های بهداشتی استفاده می شود. مخفف عبارت Subjective، Objective، Assessment و Plan است. این روشی ساختاریافته برای سازماندهی اطلاعات بیمار، از جمله علائم، یافته های فیزیکی، تشخیص و برنامه درمانی است. For example, a doctor might say, “I need to write a SOAP note for this patient’s visit. ” A nurse might document a SOAP note in a patient’s medical record, stating, “S: Patient complains of abdominal pain. O: Tenderness in the lower right quadrant. A: Suspected appendicitis. P: Order abdominal ultrasound. ” A medical student might practice writing a SOAP note for a simulated patient, saying, “Let’s start with the subjective part of the SOAP note by asking about the patient’s chief complaint. ”
