This section describes the patient’s story as you understand it. It’s a helpful acronym for remembering the main elements of any clinical note. SOAP stands for Subjective, Objective, Assessment, and Plan. For example, “81-year-old male presenting with pneumonia.” Then use the SOAP method to write your note clearly and consistently. Start by briefly summarizing the main presenting issues. Signature – Make sure to sign every entry with your name and title.For example, “Surgery progress note” gives important context if you’re in a hospital or multi-disciplinary outpatient setting. Heading – Include a descriptive header if multiple providers might edit the note.Date/time – Did you include the correct date and time of your encounter? Time is critical in emergency or ICU settings, but it can also be easy to miss if you are catching up on clinical notes at the end of the day.Patient name – Does the name on the chart match the patient you examined? Confirming the patient’s identity is especially important in a digital context, where clicking the wrong button or opening the wrong window can be easy.Before starting your note, make sure to check the following: However, minor context errors lead to enormous time lost and negative impacts on patient health. These questions are so basic they are easy to overlook. For example, are you writing in the correct patient chart? Have you included the date and time? Will the next person to read the note know who wrote it? Get the context rightīefore getting into the content of a clinical note, remember to check the context. Consider how the information you decide to include – or not include – affects the medical records’ efficacy as a form of communication, a legal document, and as a service document. Whenever you change your documentation style or workflow, it’s helpful to remember why you write clinical notes in the first place. Clear, complete, and accurately coded documentation translates into cost and revenue lines for your businesses or your employer. Whether you are self-employed or work for a hospital, medical documentation supports reimbursement. Reimbursement – Clinical notes are a service document.It is, therefore, crucial to document sensitive discussions regarding limits of care, prognosis, and treatment decisions. Legal – The medical record is a legal document that could be heavily scrutinized in the case of malpractice.It’s the most important way to facilitate high-quality patient care. Good documentation informs future providers, including yourself, what happened and how you arrived at a treatment plan. Communication – A patient record is a form of communication.There are three fundamental reasons to strive for perfect clinical notes. But remember that medical records are much more than an annoying task on your to-do list. Why write clinical notesĪs a busy doctor, high-quality documentation can become a low priority. When questions arise regarding clinical documentation, providers should always refer to their specialty-specific training and published legal guidelines. Please keep in mind: this guide is intended as a helpful reminder and compilation of best practices. In this step-by-step guide to taking perfect clinical notes, we will cover the following: Whether you’re a medical student, resident, or established physician with decades of experience, it can be helpful to go back to the basics. But as healthcare changes with new technology and reimbursement models, so should clinical documentation.
M.E.A.T. CLINICAL DOCUMENTATION PROFESSIONAL
Clinical record keeping is integral to good professional practice and quality healthcare.
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