The most common and widely accepted format of clinical documentation is the SOAP note. It addresses the legal aspect of documenting the care you provide, but it also allows for consistency across providers, which is essential in healthcare. With all providers using the same format, it allows anyone reading it to follow along with your patient’s diagnosis and management plan. So how do you use it effectively?

 

Listen in this week to hear our top do’s and don’ts as they relate to using SOAP notes for clinical documentation. Anna and I are discussing what the SOAP note entails, what to include and avoid in your documentation, and our advice for how to keep refining your clinical documentation skills.

 

Get full show notes and more information here: https://blog.npreviews.com/dos-donts-clinical-documentation/