Become confident in writing a SOAP note when you see a returning patient. SOAP stands for subjective, objective, assessment, and plan.
Become confident in writing a History and Physical note, for a complete full work-up of a new patient including review of systems, social history, etc.
Become confident in writing pre-operative note, also known as a “pre-surgical note”, to identify any new findings on a surgical candidate patient.
Brief Post-op Note
Become confident in writing a brief post operative note, after surgery write a quick outline of what was done so other doctors can be informed quickly.
Become confident in writing a complete post op note, dictated from beginning to end of everything that was done in surgery in full detail.