Doctors' notes are typically structured according to the SOAP format, and include sections on subjective, objective, assessment and planning elements of the patient encounter. According to the University of Kansas Medical Center, the subjective section pertains to the medical history of a patient, the objective refers to a physical exam of the patient, assessment involves diagnosis of the patient and planning includes the doctor's treatment decisions.
Doctors' notes begin with a section on subjective elements of the patient such as the chief complaint, history of present illness, past medical history, social history, family history and a review of symptoms in each system of the body. Next, an objective section documents a focused physical examination of the patient that includes vital signs, general impressions of the patient and exams of pertinent systems related to the patient's chief complaint. Additionally, the University of Kansas Medical Center states that the template should include a section for specific or sensitive exams such as breast exams in women or developmental screening for children.
The assessment portion of the note is designed for the doctor to note findings from the patient's history and physical and to arrive at a medical explanation and diagnosis based on previous information in the note. Finally, the planning section of the note delineates the doctor's treatment plan. As reported by the University of Kansas Medical Center, the plan may include a variety of options such as laboratory tests, imaging studies, medications and patient education.