Progress Notes

Progress Notes

Treatment given to a patient and the status of the patient is recorded in the progress notes – as well as compliance and future plans/recommendations.

SOAP format – an analytic process that allows the data to be organised:
S – subjective – the patients description of the presenting complaint
O – objective – findings
A – assessment – what is the problem?
P – plan of care

• In some clinics assessment is written under ‘O’ and ‘A’ is for ‘action’ – what was done on that particular clinical encounter.
• Other clinics use ‘SOAPIE’ – ‘I’ = intervention; ‘E’ = evaluation of intervention

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