Progress SOAP Note
S: patient comments or complaints, nursing comments.
O: VITALS: blood pressure, pulse, respirations, temp, weight, O2 sat.
INS/OUTS: IV fluid, PO intake, emesis, urine, stool, drains.
EXAM: physical findings.
MEDS: pertinent routine or new medications.
LABS: new laboratory or procedure results, not old information, just most recent.
A: assessments based on above data.
P: medication changes, lab tests, procedures, consults, discharge, etc.
Medical Notes:
Admit/Transfer Orders
Progress (SOAP) Note
Discharge Summary
Procedure Note
Discharge Summary
Off-Service Note
Pre-Operative Notes
Operative Note
Post-Operative Note
Death Note
Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult
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