When making notations in a medical record it is imperative for medical professionals to utilize a familiar charting system. This way, anyone who reads the notes will understand what was documented. Originally in the United States, only physicians were permitted to write in a patients chart; so, a more standardized medical notetaking system was developed by a doctor for other doctors (O’Sullivan & Odegard, n.d.). However, today many in the medical field notate patients charts on a regular basis.
Therefore, a charting system that is commonly used by numerous health practitioners in various medical fields is SOAP, which is an acronym that stands for subjective, objective, assessment, and plan (Hsu & Sanchez, 2016). The subjective part of the
Therefore, a charting system that is commonly used by numerous health practitioners in various medical fields is SOAP, which is an acronym that stands for subjective, objective, assessment, and plan (Hsu & Sanchez, 2016). The subjective part of the