Comparison of medical note formats
| Format | Structure |
|---|---|
| SOAP | Subjective information Chief concern History of present illness Patient’s medical, surgical, family, social history Objective information Physical examination Laboratory and test data Assessment Plan |
| APSO | Assessment Plan Subjective information (as above) Objective information (as above) |
| CAPS | Concern Patient’s chief concern History of present illness, injury Assessment Diagnosis with clinical reasoning Plan Itemized list of actions to address patient’s concerns and condition Supporting information (objective and subjective) Vital signs and physical examination Results of laboratory, radiographic, other tests Comprehensive review of systems Patient’s medical, surgical, family, social history Current medications Allergies |