Subjective: record the patient’s reported symptoms, concerns, history, and relevant statements in the patient’s own words when possible
Subjective: include chief complaint, onset, duration, severity, location, associated symptoms, and relevant past medical history
Subjective: note medications, allergies, social history, family history, and review of systems when relevant
Objective: document measurable, observable, and testable findings from the exam
Objective: include vital signs, physical exam findings, lab results, imaging, and other diagnostic data
Objective: record only facts and observations, not interpretations or opinions
Assessment: summarize the diagnosis or clinical impression based on the subjective and objective data
Assessment: list the most likely condition first, followed by differential diagnoses if needed
Assessment: note the patient’s progress, severity, and any changes from prior visits
Plan: document the treatment plan, medications, procedures, referrals, and follow-up
Plan: include patient education, lifestyle advice, monitoring instructions, and return precautions
Plan: specify dosage, frequency, duration, and any medication changes when prescribing
Use clear, concise, and professional language
Keep each section organized and labeled as S, O, A, and P
Write facts in chronological or clinically relevant order
Avoid vague terms, unsupported assumptions, and unnecessary detail
Ensure the note is accurate, complete, and consistent with the patient encounter
Review for spelling, grammar, and clinical clarity before finalizing