<P> 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 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" method of documentation for each visit . Each encounter will generally contain the aspects below: </P> <Dl> <Dt> Chief complaint </Dt> <Dd> 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 . </Dd> <Dt> History of the present illness </Dt> <Dd> A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention . </Dd> <Dt> Physical examination </Dt> <Dd> The physical examination is the recording of observations of the patient . This includes the 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 . </Dd> <Dt> Assessment and plan </Dt> <Dd> 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 .). </Dd> </Dl> <Dd> 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 . </Dd> <Dt> History of the present illness </Dt>

When must all notes and health records be completed