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Soap
The Objective section contains the following data: VS, PE, lab results, X-
ray results, diagnostic test results and current medications.
The first is to recap the patient in one or two sentences and then write out a
complete discussion of the differential diagnosis. Below this would be a
numbered list of each patient problem with the plan (meds, tests, labs,
counseling etc.) and f/u plan and time parameter for the follow up.
The second method lists each problem with an individual discussion
assessment and follow up plan.
REVIEW OF THE SOAP NOTE
First Style:
Second Style: