Answer to Question 1
In a POR, each patient is assigned one or more problems, and notes are documented for each problem using the SOAP format:
Subjective (S)-patient's statement about how he or she feels, including symptomatic information.
Objective (O)-observations about the patient, such as physical findings or lab or X-ray results.
Assessment (A )-judgment, opinion, or evaluation made by the health care provider.
Plan (P)-diagnostic, therapeutic, and education plans to resolve the problems.
Answer to Question 2
The four components include the database, problem list, initial plan, and progress notes. The database contains a minimum set of data to be collected on every patient, such as chief complaint, present conditions and diagnoses, social data, past, personal, medical, and social histories, review of systems, physical examination, and baseline laboratory data. The database serves as an overview of patient information. The problem list acts as a table of contents for the patient record. It is filed at the beginning of the record and contains a list of the patient's problems. The initial plan describes actions that will be taken to learn more about the patient's condition and to treat and educate the patient. The progress notes summarize the patient's care, treatment, response to care, and plans to resolve problems.
