Compiling progress notes was never so easy like it stands now
Posted: Jan 09, 2014
Today's modern medical hemisphere has been blessed with the sample SOAP notes, which play an inevitable role. All thanks to the ever growing internet technology that has painted everything by making the things go hassle free and easy.
Soap notes are amid one of the most misunderstood concepts for those who have never been into it much. Of course, that includes all the people who are not related to medical field by any means and for them this is something too big to understand in its most appropriate manner. In the most simple terms, the word SOAP encompasses a big proportion of the entire documentation process that is prepared by the doctors and the physical therapist altogether. Breaking down the word into even smaller terms then it could mean Subjective, Objective, Assessment and Plan note. Since all the medical practitioners have to maintain a whole hosted series of documents for keeping a close vigil over the patient's ongoing health condition, preparing a sample Soap note is just the way to get along. However, when it comes to the reimbursement of the insurance claim then also it is the soap note that makes a big count on the way, no matter what.
The very first thing is the Subjective stage!
In this phase jotting down all the events that comes from the personal observation are included. Now this could be in either of the ways, like what patient has told or what did the doctor has observed from the pre-examination. This is the basic and the very stage therefore much of the diagnosing isn't carried out and a per what patient's say or the doctor observes is mentioned in the notes.
The later one is the Objective stage!
Objective phase includes simple pre-diagnosis stages of the problems where the medical practitioner in charge records all the symptoms collected by him by visual observation or by some basic checkups.
After that is the Assessment part!
This is one of the most important phases in the entire note taking process. It includes all the necessary diagnosis of the problems to get through the veins of it and then suggesting the most appropriate treatment for the same.
Lastly, it is the Plan!
The plan stage makes up the base of the entire progress notes making process. This stage includes all the findings that have been drawn from the aforementioned phases. All the researches and findings are compiled at the final stage which is the plan stages. Necessary treatments, medications or even surgery, if needed, is directed by the governing doctor after having a detailed insight of the problems. And that's how the entire note making process goes on and on.
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