This is a complex question that depends on your role, your specialty, and the system that you may be used within your organization. But one thing remains the same across the board...Document from a legal perspective and you will be in the best position to defend yourself and the care that you provided.
That sounds easier said than done and honestly, you may forget my words so I decided to create a guide that you can download and carry with you no matter where you are.
What is in the Guide:
- When to use SOAP versus expanded SOAP
- Key Areas of Documentation
- Resources, Tools, and Tips
- Expanded SOAP Note definitions and examples
- How to Use the Tool
- Mini-Course: Questions That Need Answers
- Case Study/Resource Link