The "SOAP" -- subjective, objective, assessment, plan -- format has been in common use for decades as a way of organizing physician progress notes in medical records, but it was created during a ...

Physicians’ style of note-taking could affect the quality of care they provide, according to a study published in the Journal of the American Medical Informatics Association. The study examined ...

When reading electronic notes in patients’ electronic medical records, physicians focus mostly on the “Impression and Plan” section and have a tendency to skim the sections covering medications, vital ...

Peeking at physician notes in a medical chart is a bit like snooping through someone else’s diary because you never quite know what you’ll find. Will it be a perfectly mundane summary of vitals and ...