Offering step-by-step guidance on how to properly document patient care, this updated Second Edition presents 90 of the most common clinical problems encountered on the wards and clinics in an easy-to-read, two-page layout using the familiar "SOAP" note format. Emphasizing the patient’s clinical problem, not the diagnosis, this pocket-sized quick reference teaches both clinical reasoning and documentation skills and is ideal for use by medical students, Pas, and NPs during the Family Medicine rotation.
• A new Introduction offers templates, tips, and guidelines for writing SOAP notes.
• Clear, well-written sample SOAP notes for a wide range of diagnoses focus on the most important information needed for success on rounds.
• A portable, pocket-sized format with at-a-glance, two-page layouts makes practical information quickly accessible.
• The SOAP approach helps students figure out where to start, while improving communication between physicians and ensuring accurate documentation.
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