S.O.A.P. notes make your assessment and treatment logical and keep your records clear.
S = Subjective; what the patient tells you i.e. symptoms you cannot see such
as pain or how they are feeling, and details
about family or living conditions
O = Objective; what you see (e.g. signs of infection or range of movement) and what you do (treatment given)
A = Analysis: what might be happening, e.g. show clinical reasoning
P = Plan: what you want to do next time, such as add a new treatment as
patient progresses
When you are ready, please proceed to the assessment of your patient.