Editing Medical record (section)

===Medical encounters===

Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a [[medical specialist|specialist]] often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the ''problem-oriented medical record'' (POMR), which includes a problem list of diagnoses or a "[[SOAP note|SOAP]]" method of documentation for each visit. Each encounter will generally contain the aspects below:

;[[Chief complaint]]
:This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor or other clinician. Information on the nature and duration of the problem will be explored.
;[[History of the present illness]]
:A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
;Physical examination
:The [[physical examination]] is the recording of observations of the patient. This includes the [[Vital signs (medicine)|vital signs]], muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.
;Assessment and plan
:The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).