This updated Second Edition provides detailed guidance on documenting patient care in a step-by-step manner. It features 90 common clinical problems in a user-friendly two-page layout using the “SOAP” note format. The emphasis is on the patient’s clinical problem rather than the diagnosis, making it an ideal quick reference for medical students, Pas, and NPs during the Family Medicine rotation. The new Introduction includes templates, tips, and guidelines for writing SOAP notes. Sample SOAP notes cover a wide range of diagnoses, focusing on essential information for success on rounds. The portable, pocket-sized format with two-page layouts allows for quick access to practical information. The SOAP approach aids students in determining where to begin, enhancing communication between physicians, and ensuring accurate documentation.

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