Medical Assistant Prep / Unit 11 MAS 268 worked example, 60 to 90 seconds
The Progress Note and Your Part in It
The idea
One common format for progress notes follows the letters S, O, A, P, and sometimes I and E.
In practice
S is subjective: what the patient said, such as "I have a headache." O is objective: observable and measurable data, such as vital signs and test results. A is assessment: the interpretation of S and O, which in a provider's note is the medical diagnosis. P is plan: the planned care. I is interventions: the actions taken. E is evaluation: how the patient responded.
Where people slip
The medical assistant mainly gathers the S and O that make up the note's foundation. The assessment and plan require clinical judgment and belong to the provider, so do not write a diagnosis into the subjective or objective section.
Your place on the trail
Every lesson rests on earlier ones and opens later ones. Tap any to jump.
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