A patient's office visit is found in what type of document?

• A. Discharge Summary
• B. SOAP note
• C. Progress Report
• D. Consent Form

Answer: (B)

Documenting an office visit is typically done with a SOAP note structure. This format organizes the encounter into four parts: Subjective information (the patient’s reported symptoms, history, and concerns), Objective information (measured data like vitals and physical exam findings), Assessment (the clinician’s diagnosis or impression), and Plan (the proposed treatment, tests, prescriptions, and follow-up). This setup is specifically suited to outpatient care, clearly capturing what the patient says, what the clinician observes, the diagnostic reasoning, and the next steps.

Discharge summaries are used when a patient leaves a hospital to summarize inpatient care. Progress reports describe ongoing status over time and are not the standard single-visit record in an office. Consent forms document informed consent for a procedure, not the full encounter notes.