10/30 Reporting Assessment Findings continued Flashcards
1
Q
What are some guidelines we need to remember regarding reporting assessment findings?
A
- Does it contain all of the major information needed?
- Is the information appropriately categorized?
- Is there redundancy?
- Is it too wordy? Sentences too long?
- Terminology used correctly?
- Written objectively?
- Are the “facts” truly based on fact?
- Is the focus on the major points?
- Does the report contain ambiguities that could be misinterpreted?
- Is the report written in logical progression?
- Are the mechanics appropriate?
2
Q
What does the clinical correspondence consist of?
A
- Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule
- ASHA/CSHA: Code of Ethics, Best Practice
3
Q
What is the purpose of writing SOAP notes?
A
- Reporting clinical information
- Facilitates communication between professionals
4
Q
What does SOAP notes stand for?
A
Subjectove
Objective
Assessment
Plan
5
Q
What does the subjective part include?
A
non-measurable information
6
Q
What does the objective part include?
A
measurable information findings
7
Q
What does the assessment part include?
A
For diagnostics, write conclusions/recommendations. For therapy, record current status in relation to goals
8
Q
What does the plan include?
A
It is your plan of action (next steps)
