Subjective, Objective, Assessment, and Plan — is the template for documentation health care providers use for medical charting.

Here is an outline of its four points:

S: based on the initial interview (details at the link above). The translation should be in the present tense when possible; acronyms must go through the fundamentals of translation, research, and expansion on first use.

O: observations and measurements — Hence, the details in the article may prove useful in deciphering abbreviations or symbols, along with the WHO’s ICD-10 codes and

A: medical diagnosis. Generally done in descending order of the severity of symptoms. So, pay attention to hypotheticals and verbs, their varying degrees (i.e. severity); and use “doctor-facing register.” For section’s lab results, you can use

P: the next steps. If in list format, the imperative is recommended. Thus, be wary of correct spellings for drugs and devices, and clarify Latin acronyms. Also: practice being succinct; avoid overuse of acronyms/abbreviations; document your research, and read online SOAP notes (style familiarization).

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