Offering step by step guidance on how to properly document patient care, this updated Second Edition presents 90 of the most common clinical problems encountered on the wards and clinics in an easy to read, two page layout using the familiar “SOAP” note format. Emphasizing the patient’s clinical problem, not the diagnosis, this pocket sized quick reference teaches both clinical reasoning and documentation skills and is ideal for use by medical students, Pas, and NPs during the Family Medicine rotation.

• A new Introduction offers templates, tips, and guidelines for writing SOAP notes.
• Clear, well written sample SOAP notes for a wide range of diagnoses focus on the most important information needed for success on rounds.
• A portable, pocket sized format with at a glance, two page layouts makes practical information quickly accessible.
• The SOAP approach helps students figure out where to start, while improving communication between physicians and ensuring accurate documentation.