About the Document tab
The Document tab in Medical Note serves as your primary note for a patient visit, structured in accordance with the SOAP (Subjective, Objective, Assessment, Plan) format.
Subjective
Document the patient's reason for the visit in their own terms. Typically, this includes the chief complaint and History of Present Illness (HPI). The chief complaint describes the reason behind the patient seeking medical attention, which can encompass an existing chronic condition, a previous condition, or a new symptom. The HPI, usually the most extensive section, includes information such as location, quality, severity, duration, timing, context, associated signs/symptoms, and modifying factors.
Gather a comprehensive history that includes medical, family, surgical, and social aspects. Also conduct a Review of Systems (ROS), a series of closed-ended questions categorized by body system, aimed at identifying relevant signs and symptoms.
Objective
Record factual observations from the patient's visit. This typically involves a physical examination or mental status examination, review of laboratory results or other diagnostic findings, and a review of clinical documentation from other providers.
Assessment
Review the problem list and potential diagnoses pertinent to the visit.
Plan
Describe the plan or course of action, including potential referrals, additional testing requirements, and the specifics of treatment modalities to address the identified issues.