Ch. 13: Documentation

Question 1

Why do we document? 3 Reasons

Answer 1

1. Communicate with Co-workers
2. Protect Ourselves
3. Get paid

Question 2

Name some things to document:

Answer 2

Evaluations, symptoms and signs, signatures and permissions, procedures, time on the clock, everything

Question 3

What does SOAP notes stand for and what is it used for?

Answer 3

Subjective Information, Objective Information, Assessment, Plan of recovery

Quick overview.

Question 4

What are some subjective pieces of information?

Answer 4

MOI, Information from the patient, pain, past medical history, medications, OPQRST

Question 5

What are some objective pieces of information?

Answer 5

Vitals, tenderness, skin color, visual inspection, neurological inspections, anything that can be: measured, quantified, or qualified

Question 6

What is the assessment portion of SOAP notes?

Answer 6

Declaring patient’s conditions based on subjective and objective pieces of information

Question 7

Plan?

Answer 7

Anything that should be done to improve health. Including:

Goals, dates for treatments, referrals, exercises, education/advice

Question 8

10 Guidelines of documentation:

Answer 8

1. No white out or erasing
2. No access to relatives
3. Fill out only for yourself
4. Avoid General statements
5. Begin entries with date, name, and title
6. Only facts
7. No blank spaces
8. No opinions
9. Eligible with ink
10. Clarification to any questions