Clinical Documentation Strategies


Many providers continue to use SOAP Notes to document a patient’s progress.  SOAP Notes can now be found in electronic forms depending on the system a clinic or provider might use.  However, SOAP Notes may not be the perfect form of documentation for all settings.

School-Based therapists are now beginning to use rubrics to meet the standards set forth in the IDEA.  Therapists in school-based settings often write lengthy evaluations with several standardized measures.  Now, school districts are looking for a more ‘balanced’ assessments which include ‘authentic’ or real-life documentation as well.  A rubric is a form of documentation that meets the ‘authentic’ criteria.

Many hospitals use a number of protocols, checklists and task analyses to meet the documentation requirements of Medicaid and Medicare.  In whatever setting you work, there is a real effort to standardized documentation to meet the standard of care.  Gone are the days of the simple SOAP Note.

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