Description: Observation Notes are written records that document the observations made during a patient’s evaluations. These notes are fundamental in the healthcare field as they allow health professionals to systematically and organizedly record clinical findings, behaviors, and patient reactions. Their structure is based on the SOAP format, which includes four components: Subjective, Objective, Assessment, and Plan. This approach facilitates communication among healthcare team members and ensures proper follow-up of the patient’s condition. Observation Notes are not only crucial for continuity of care but also serve as a legal and administrative resource, providing a clear record of decisions and actions taken during the care process. Additionally, these notes can be used for research and medical education, contributing to the development of better practices in patient care.
