Medical terminology ? ? i have to write a soap note with the info i’m given but i have no idea how

SOAP notes refer to a particular format of recording info regarding treatment procedures. Documenting treatment is an extremely important part of the treatment process they are supposed to be brief, informative, and focus on what others need to know.

S- Subjective—— the patient describes their symptoms and what brings them to the clinician.

O- Objective—— the clinician reports measurable and observable information.

A- Assessment—— clinician reports their impression/summary based off of the assessment/examination, this is the diagnosis.

P- Plan—— where the clinician outlines the plan of action based off of the assessment and evaluation/assessment. Short term and long term goals are listed here.

We don’t know what you want to ask us