Patient records
(SdotOdotAdotP)

patient records
 
 
patient records

Analysis notes

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Subjective assessment

Record what the patient tells you

patient assessment

Red flags red flags

Red flags are warning signs or symptoms that suggest a serious underlying disease

Please seek medical help if any of the above apply

Analysis notes

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S

S.O.A.P. notes make your assessment and treatment logical and keep your records clear.

S = Subjective; what the patient tells you i.e. symptoms you cannot see such as pain or how they are feeling, and vital details about family or living conditions
O = Objective; what you can see i.e. signs such as heat, redness, range of movement and what treatment you might give such as which exercise, or how many and how often
A = Analysis: what you question may or may not be happening, so reasoning through a problem such as progress the patient is making comes in here
P = Plan: what you want to do next time, such as add a new treatment as patient progresses

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O

Example
for a patient with amputation

Hover over the blue numbers to see its relevant note

Hover over the blue numbers to see its relevant note

READY?

When you are ready, please proceed to the assessment of your patient.