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documentation, electronic health record, history and physical exam, SOAP note



  1. Pearce, Patricia F. MPH, PhD, FNP-BC, FAANP, FANP
  2. Ferguson, Laurie Anne DNP, ANP-BC, FNP-C, CPNP
  3. George, Gwen S. MSN, DNP, FNP-BC
  4. Langford, Cynthia A. MSN, PhD, FNP-BC


Abstract: This article reviews the traditional Subjective, Objective, Assessment, and Plan (SOAP) note documentation format. The information in the SOAP note is useful to both providers and students for history taking and physical exam, and highlights the importance of including critical documentation details with or without an electronic health record.