Conventions: The age and name of the patient is repeated, possibly for record keeping, to distinguish patients, and due to such information, particularly the age, being relevant for medical care.

Such assessment can help explain the release of the patient.

Tone and Style: The tone and style are technical, as the document is composed of incomplete sentences, with non-emotional facts, and no obvious errors. The sentences are short, allowing for efficient reading of the document, including only the necessary information.

Conventions: The document repeats the information that the patient declined medication. This information is important for follow-up care, especially such at a different facility, or for lawyers in the case of a dispute.

Legal importance; displays the use of the legal holding of the patient.

Audience: The audience is directed towards healthcare workers, particularly those who are providing the follow-up care. Additionally, in the rare case of disputes with the medical care provided, the audience could be for lawyers, either those of the hospital or of the patient.

Conventions: The capitalized headings are repeated for an organized structure within the document, separating and identifying the relevant information presented. This allows for the efficient reading of the important information from the patient's visit at the healthcare facility.

Medical history that is relevant to the current condition of the patient.

Purpose: The purpose of the discharge summary is to summarize the patient's condition, assessments, stay, reasons for discharge, and discharge process. This summary of the visit to the medical facility as a precedent for additional care, documents the medication the patient was prescribed and receiving, ensures the hospital/facility is not liable if the patient attempts to dispute, and serves as documentation for insurance purposes.

Structure: The discharge summary is organized by headings that separate the relevant information required for additional care or liability disputes. Underneath are short sentences that explain every important step in the patient's process throughout their stay at the hospital or healthcare facility, and the plan or their medication afterwards.

Conventions: The patient's allergies, medication, and medical history is repeated due to the possible impacts of such on the current treatment plan.

Tone and Style: The report is written using a technical style of short, incomplete sentences, including clear, necessary facts on the relevant patient information for providers. This tone does not include emotional language regarding the patient. This allows for only the necessary information on the patient to be stated for efficient reading of the document.

Conventions: The diagnosis of pneumonia, sepsis, and a cell lung carcinoma, is repeated throughout the document, with the treatment for such below these subtitles. This is used to emphasize the treatment the patient is currently undergoing.

Conventions: The patient's background of stage IV cell lung carcinoma is repeated, highlighting such as an important factor in the patient's medical history and current treatment.

Structure: The bullet point format allows for the quick reading of the important information regarding the patient's background, working diagnosis, and summary.

Conventions: The patient name, birth date, and medical record is repeated as confirmation each additional page addresses the same patient.

Audience: The audience is centered towards nurses, physicians, or other healthcare professionals, to provide a quick turnover during shift changes or other rotations. This information allows for efficient care, providing all the necessary information for proper patient care, without requiring an prolonged discussion between providers.

Conventions: The use of tobacco in the patient's social history exemplify the impact of such on his condition and treatment. Additionally, semi-colons are utilized throughout the document for incomplete sentences, allowing the information to be read quickly.

Displays the health state of the patient before seeking the current medical care.

Purpose: The various headings and summarized information below allow for the efficient reading of the patient's medical history, medications, social history, and diagnostic information. Such information includes the relevant knowledge needed for proper medical care, particularly identifying information that could impact the treatment or health of the patient.

Structure: The patient turnover has various headings and incomplete summaries of the relevant medical history, medications, social history, diagnostic information, recommendations, and action plans for nurses and providers. Such allows for efficient patient handoff, with summarized, incomplete sentences, which allows for expedited scanning for necessary information.

Important to the diagnosis.

Important to the diagnosis.

Important to the diagnosis.

Distinguishes the statement of the patient from the assessment of the healthcare provider.

Important for legal disputes, allowing the identification of the provider.

Conventions: The name of the practitioner is included for the identification of the document, incase multiple practitioners assess one patient, record-keeping, legality, incase of disputes, and for document or patient transfer to another field or facility.

Conventions: The date is repeated, presumably for proper filing or record-keeping, accountability, patient transfer, or research purposes. Additionally, the time the document was initiated and the time the document was finalized and signed by the physician, is included for similar reasons, particularly that of patient transfer.

Conventions: The picture of the patient's condition is repeated because the initial photo was reduced in size to fit on the primary document page. The second photo provides a larger picture of the condition at the end of the document.

Conventions: The phrase "Private & Confidential" is repeated at the bottom of every page, coinciding with HIPPA and stressing the importance of keeping the patient's medical and personal information classified.

Tone and Style: The tone and style of this document is mostly technical, but also partially informal. The physician uses short sentences with clear facts regarding the patient's condition. However, the technical writing style typically requires formal writing. While the document includes relatively complete sentences with proper punctuation, there are few errors, including the highlighted portion for this annotation. Therefore, the document may not be able to be referred to as entirely technical.

Structure: The structure of the document includes headlines and summarized relevant information about the subjective and objective data, the assessment of the physician, and the plan for treatment. This allows for efficient reading of the document and serves as a record for the treatment of the physician. Additionally, the headings provide a template for the steps the physician or possibly student should take, and provides organization to the document.

Audience: The audience ranges for SOAP notes. Such can be utilized by the original physician themself, other follow-up healthcare professionals, hospital administrators, educators in hospitals or medical schools, and the students of such, and potentially the patient themself. The direct audience of SOAP notes is physicians, as the healthcare providers are intentionally writing the notes for other clinicians.

Purpose: The Plan, or P, outlines the next steps for the patient or healthcare facility to take. This includes the treatment, follow-ups, and patient education, that is assigned based on the patient's diagnosed condition.

Purpose: Assessment, or A, summarizes the diagnostic impression on the provider, outlining the provider's analysis of the subjective and objective data.

Purpose: O, or objective, explains what the provider is observing, recording the measurable data, factual data, and, sometimes, a supporting picture of the condition.

Purpose: SOAP notes allow healthcare providers to track, record, and communicate the condition and care of the patient over time. S, or subjective, records the patient's perception of their condition, including their symptoms, own assessment, and medical history.