The essential SOAP note in an EHR age.

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.

[1]  J. Conway,et al.  Integration of an Internet-based medical chart into a pharmacotherapy lecture series. , 2007, American journal of pharmaceutical education.

[2]  L. Weed.  Medical records, patient care, and medical education , 1964, Irish journal of medical science.

[3]  Alastair Baker,et al.  Crossing the Quality Chasm: A New Health System for the 21st Century , 2001, BMJ : British Medical Journal.

[4]  R. Young,et al.  Family physicians' opinions on the primary care documentation, coding, and billing system: a qualitative study from the residency research network of Texas. , 2014, Family medicine.

[5]  H. Simon,et al.  Over-the-counter medications. Do parents give what they intend to give? , 1997, Archives of pediatrics & adolescent medicine.

[6]  Jonathan Pell,et al.  Health care provider satisfaction with a new electronic progress note format: SOAP vs APSO format. , 2013, JAMA internal medicine.

[7]  richard F leblond,et al.  DeGowin's Diagnostic Examination , 1999 .

[8]  Carol A. Smith,et al.  Educating Advanced Practice Nurses for Collaborative Practice in the Multidisciplinary Provider Team , 2004, Journal of the American Academy of Nurse Practitioners.

[9]  M. Godwin,et al.  What drugs are our frail elderly patients taking? Do drugs they take or fail to take put them at increased risk of interactions and inappropriate medication use? , 2001, Canadian family physician Medecin de famille canadien.

[10]  Lee Jacobs.  Interview with Lawrence Weed, MD- The Father of the Problem-Oriented Medical Record Looks Ahead. , 2009, The Permanente journal.

[11]  John Q. Young,et al.  The Systems SOAP Note: A Systems Learning Tool , 2016, Academic Psychiatry.

[12]  K. Blake,et al.  Raising our HEADSS: adolescent psychosocial documentation in the emergency department. , 2004, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[13]  Barbara Bates,et al.  A guid to physical examination and history taking , 2013 .

[14]  Elizabeth Yakel,et al.  Documentation and the Nurse Care Planning Process , 2008 .

[15]  Erik Langenau,et al.  Keyboard Data Entry Use Among Osteopathic Medical Students and Residents , 2014, The Journal of the American Osteopathic Association.

[16]  Jeanne E. Frenzel.  Using Electronic Medical Records to Teach Patient-Centered Care , 2010, American Journal of Pharmaceutical Education.

[17]  R. Moon,et al.  SOAP for Internal Medicine , 2004 .

[18]  L. Kohn,et al.  COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA , 2000 .

[19]  R. Hughes.  Patient Safety and Quality: An Evidence-Based Handbook for Nurses , 2008 .

[20]  L. Weed.  Medical records that guide and teach. , 1968, The New England journal of medicine.

[21]  W. Baine,et al.  The Agency for Healthcare Research and Quality , 2006, Italian Journal of Public Health.

[22]  E. Cohen,et al.  Off the Record — Avoiding the Pitfalls of Going Electronic , 2009 .

[23]  Dean F Sittig,et al.  Bringing science to medicine: an interview with Larry Weed, inventor of the problem-oriented medical record , 2014, J. Am. Medical Informatics Assoc..