AAP Charting

SOAP Notes

CNPP students are expected to chart using a subjective, objective, assessment, and plan (SOAP) note.

• The student will complete a written SOAP note for each patient encounter. It must be written in a clear succinct method (Podder, Lew & Ghassemzadeh, 2020).
• The student will chart the SOAP notes either electronically or in paper charts or files. Preceptors are required to review each note to ensure accuracy and will co-sign the note, a legal requirement of care.
• Preceptors will provide feedback and guidance to help students improve their charting. It is recommended that students who are in the learning phase do not use electronic macro adjustments in charting as this may impede their learning. Writing a succinct note that communicates effectively is a critical skill that AAP students must develop.

Students are expected to write prescriptions, order diagnostics, write referrals, and consult letters for the patient. The preceptor must co-sign all clinical documents.