Summary of Health Record Notes

Prescription (Author: Medical professional)

Provides directions for a medication Format and Order: P Unique Features: 1. Medicine's name 2. Instructions for patient 3. How much medicine should be given 4. Refills, if any 5. Health care professional's signature and whether generic substitution is allowed

Pathology Report (Author: Pathologist)

Provides reasons for test, what was seen on the test, and an assessment Format and Order: SOA

Clinic Note (Author: Medical Professional; Location: Clinic)

Purpose: Documents a visit Format and Order: SOAP Unique Features: New patient: includes more history, separate form - Repeat patient: Streamlined note

Emergency Department Note (Author: ED medical staff; Location: ED)

Purpose: Documents an ED visit Format and Order: SOAP Unique Features: The A includes the ED course

Admission Summary (Author: Hospital medical professional; Location: Hospital)

Purpose: Documents the admission of a patient to the hospital Format and Order: SO A/P Unique Features: S,O = Very thorough , A= Differential diagnosis , P= Further testing and care, A+P= Problem-based Approach

Consult Note (Author: Physician; usually a specialist; Location: Clinic or hospital)

Purpose: Provides an expert opinion on a more challenging problem Format and Order: SOAP Unique Features: Can be in the form of a letter to the PCP

Operative Report (Author: Surgeon)

Documents a surgery in detail Format and Order: ASOP

Discharge Summary (Author: Medical professional; Location: Hospital)

Describes when and why the patient was admitted; documents a longer stay Format and Order: ASOP Unique Features: Starts with A

Daily Hospital Note/ Progress Note (Author: Medical professional; Location: Inpatient health care facility)

Documents daily hospital visit Format and Order: SO A/P Unique Features: S-Focuses on how patient's condition has changed since the previous note, A-Sometimes includes a differential diagnosis

Radiology Report (Author: Radiologist)

Explains reason for image, how image was performed, what was seen on image, and radiologist's assessment; sometimes includes a recommendation Format and Order: SOA Unique Features: Usually includes only S, O, and A, but may include P if it recommends that further studies should be performed