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Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1]
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
As of December 2015, there are more than 2,000 retail clinics located in 41 states and Washington, DC in the United States. [2] Retail clinics are staffed by physician assistants or nurse practitioners and most are open seven days a week – twelve hours a day during the workweek and eight hours a day on the weekend. [3]
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A nurse operating medical equipment in an ambulatory care setting. Ambulatory care services typically consist of a multidisciplinary team of health professionals that may include (but is not limited to) physicians, nurse practitioners, nurses, pharmacists, occupational therapists, physical therapists, speech therapists, and other allied health professionals.
An Operative report is a report written in a patient's medical record to document the details of a surgery. [1] The operative report is dictated right after a surgical procedure and later transcribed into the patient's record.
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