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In this tutorial, Dr. Decide discusses how to write an effective progress or clinical note using the SOAP format: Subjective, Objective, Assessment, and Plan. The subjective section captures the patient's reported information, while the objective section includes findings from physical exams, lab results, or imaging. The assessment reflects the clinician's thought process about the patient's condition, and the plan outlines the next steps for treatment or intervention. Dr. Decide emphasizes the importance of this format, detailing key elements to include for clarity and effectiveness in documentation.
