Progress Note: This is the most likely scenario. Progress notes are written by healthcare providers throughout a patient’s hospitalization or course of treatment. They document the patient’s current status, any changes since the last note, interventions, and response to treatment.
Discharge Note: This is a comprehensive note written upon a patient’s discharge from a healthcare facility. It summarizes the reason for admission, key events during the stay, discharge diagnosis, medications, follow-up instructions, and prognosis.
Consultation Note: This is a note written by a specialist after seeing a patient referred by another physician. It documents the reason for referral, the specialist’s assessment and recommendations, and any planned communication with the referring physician.
SOAP Note: SOAP (Subjective, Objective, Assessment, Plan) is a common note format used in various healthcare settings. It structures documentation chronologically, capturing the patient’s perspective (Subjective), objective findings from examination (Objective), the healthcare provider’s assessment (Assessment), and the treatment plan (Plan).