Information Carried by Paper File of Doctor or Electronic Charts

ElectronicStandard SAOP is used in the paper file of a doctor's office or the electronic record in the clinic's computer. There are a number of points that a person must understand, at least the basics of the doctor language.

S in the SAOP stands for subjective. This part carries information of the medical history. It fleshes out details of patient's symptoms, such as the type of pain experience; its location, quality, intensity and duration. It involves all those aspects that govern the pain of an individual.

O is objective. It includes the consequences of earlier investigations and the findings on the physical examination. It speaks about the facts concluded by doctors, measured figures and also conclusions of stethoscope.

Next in line is assessment. It is the diagnosis or multiple possible diagnoses that can be possible. It is an amalgamation of all those points that may be confirmed or discarded.

P stands for plan and it carries all the recommended treatments that must be given to the patients. It is important for doctors to make these notes. It is important for the clarity of any individual's medical history.

The electronic charts include investigations, that includes X-rays, scans and lab tests; admission, operative and discharge reports from hospitals; and the consultation letters from specialists.