Crafting the ideal patient progress note, at least judging from the literature, seems more easily achieved in theory than in execution. Since the late 2000s, when the electronic health record replaced ...

Several weeks ago, a patient of mine was admitted to the hospital. Reading through the admission notes, from the triage by the emergency department (ED) through the admitting team, I unfortunately was ...

The "SOAP" -- subjective, objective, assessment, plan -- format has been in common use for decades as a way of organizing physician progress notes in medical records, but it was created during a ...