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Veterinarians, MD's, Etc. Are trained to fill out using the SOAP method. S = Subjective or the owners information. O = Objective which is what the doctor discovers - significant medical information about the patient. A = Assessment. This is the presumptive diagnosis or a set of rule-outs. The P = Plan which is: what are we going to do?"
This is the ground floor building base for everything. I'm surprised it isn't an automatic for every client!
James W. Eubank, DVM - Black Horse Animal Hospital, Gap, PA