After a Doctor’s Appointment

Your healthcare is most important to you!

After your appointment, it is important to ensure the care plan is followed. Your care plan, detailing the next steps, is included in the ‘notes’ that the doctor writes to document the appointment.

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Doctors use the SOAP format to quickly and efficiently summarize the appointment for you, other providers, and your insurance company. SOAP stands for Subjective, Objective, Assessment, and Plan. You can find the notes from your appointments, hospital, and ER visits in the patient portal of your electronic medical records.

SOAP Notes

Subjective: What you, the patient, have shared about your chief complaint, including symptoms, history, and concerns.

Objective: Is objective data the doctor has gathered including vital signs, physical exam, and other diagnostic testing results?

Assessment: A 1-2 sentence summary of the doctor’s assessment that includes things like the patient’s age, relevant medical history, major diagnosis, and a differential diagnosis with several possibilities.

Plan: A list of all patient’s medical problems ordered by importance with a plan to manage each problem identified. The plan includes lab orders, radiological work, referrals, procedures performed, medications given, and education provided.

Things to Think about After the Appointment

What is the plan? Why?
Who will be doing it?
When can I expect it?
Who can I contact for help?
What is the best way to reach you?

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