Publisher: Wolters Kluwer,
Publication Year: 2019,
Ideal for medical students, PAs and NPs, this pocket-sized quick reference helps students hone the clinical reasoning and documentation skills needed for effective practice in internal medicine, pediatrics, OB/GYN, surgery, emergency medicine, and psychiatry. This updated edition offers step-by-step guidance on how to properly document patient care as it addresses the most common clinical problems encountered on the wards and clinics. Emphasizing the patient's clinical problem, not the diagnosis, the book's at-a-glance, two-page layout uses the familiar SOAP note format.
NEW! An expanded "How to Write a Soap Note" introduction provides templates, tips, and guidelines for writing soap notes.UNIQUE: No other resource teaches clinical information and documentation through the use of a SOAP (Subjective, Objective, Assessment, Physical Exam) format.PORTABLE: The book is small, portable, and easily fits into a lab coat pocket--perfect for taking along on rounds.EASY-TO-ACCESS: At-a-glance, two-page layouts provide practical information using the familiar SOAP note format.FOCUSED: Clear, well-written sample SOAP notes for a wide range of diagnoses emphasize the most important information needed for success on rounds.ACCURATE: The SOAP approach helps students figure out where to start, while improving communication between physicians and ensuring accurate documentation.