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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. [9]
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
A shoulder examination (or shoulder exam) is a portion of a physical examination used to identify potential pathology involving the shoulder. It should be conducted with both shoulders exposed to assess for asymmetry and muscle wasting.
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In both tests, the patient is placed in a standing or sitting position, and the arms are raised parallel to the ground in the scapular plane. [2] The tests differ in the rotation of the arm; in the empty can test, the arm is rotated to full internal rotation (thumb down) and in the full can test, the arm is rotated to 45° external rotation, thumb up. [1]
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