The encounter will be documented in standard SOAP (Subjective, Objective, Assessment, Plan) note format.  The Subjective section contains all the pertinent information that comes from the patient; the Objective includes relevant physical exam findings and vitals, and the Assessment/Plan includes your diagnosis and what supports that diagnosis, plan of action (medication given or patient referred), disease and medication specific education given to the patient, and follow up plan.

Close Bitnami banner