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SOAP Note

When rounding, notes written in the patient’s chart may be written in the SOAP note format:

S: Patient subjective findings (pain, SOB, CP, etc.)

O: Patient objective data (Vital signs, lab data, Is & Os, physical exam findings, etc.)

A: Assessment (POD# and surgical procedure, medical issues/conditions, other injuries, etc.)

P: Plan (PT, WBS, medications, DVT prophylaxis, NPO for OR today, etc.)