What type of note is designed to emphasize specific patient problems and encourages ongoing assessment?

The SOAP note format is specifically designed to facilitate the documentation of patient encounters in a structured manner that emphasizes specific patient problems. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan.

The subjective section captures the patient's own words about their symptoms or concerns, providing valuable insight into their experiences. The objective section contains measurable or observable data, such as vital signs and physical examination findings. The assessment segment synthesizes the subjective and objective information into a clinical judgment about the patient's condition. Finally, the plan outlines the next steps for treatment and any further evaluation needed, encouraging ongoing assessment and follow-up.

This structured format supports clear communication among healthcare providers and can easily adapt to an evolving understanding of patient issues, making it a tool for both clinical efficiency and quality patient care.

Other note formats like POMR, HPIP, and CHEDDAR have unique characteristics but do not focus as explicitly on the continuous assessment of specific patient problems in the same way SOAP notes do.