What do patient notes include?
After every appointment, you will be given a copy of your patient chart notes covering everything from your appointment, including your treatment plan at home and follow up needs.
In our office, we use the SOAP note format (Subjective, Objective, Assessment and Plan):
Subjective: The subjective part of your note includes the reason for your visit, your past medical history, allergies and current medications.
Objective: The objective contains a description of your wound or skin condition, including any measurements.
Assessment: The assessment contains your diagnosis, or the medical term for what is described in your objective.
Plan: The plan outlines what to do for treatment. It may include what type of wound dressings or medications to use, as well as how often to repeat the treatment. Your plan will also tell you the recommended time for you to book a follow up appointment.
Common Acronyms on our SOAP Notes:
AVSS = All vital signs stable
DPD = Dry, protective dressing
DP pulse = Dorsalis pedis pulse (pulse on the top of your foot)
ENT = Ears, nose, throat
GI = Gastrointestinal
GU = Genitourinary
HPI = History of present illness (similar to past medical history)
LE = Lower extremity (legs), including RLE (right lower extremity) and LLE (left lower extremity)
NKDA = No known drug allergies
PCP = Primary care physician
PMH = Past medical history
PO = per os (as in taking medication by mouth)
PRN = Pro re nata (as needed)
PT pulse = posterior tibial pulse (pulse on your ankle)
UE = Upper extremity (arms), including RUE (right upper extremity) and LUE (left upper extremity)