The application of good chart note practices is exemplified through continuous

externships gain experience in clinical encounters & patient education

Criteria for upholding good quality healthcare documentation & best practices
>the account-specific client profile
>AHDI Guidelines-Book of Style & Standard for Clinical Documentation
>HelloRache Good Chart Note Practices for HVAs

The ABCs of Writing Medical Records

>Accuracy
>Brevity
>Clarity

Charting the SOAP Notes:

Chief Complaint - The presenting problem
- The reason why the patient is seeing the provider
Subjective - "subjective" experiences, personal view or feeling of the patient
- Includes the HPI and ROS
>History of Present Illness
-Elaboration of the chief complaint as narrated by the patient
-The first sentence should be the main reason for the visit
-Chart using the present tense
-Must be comprehensive
-Must describe the signs or symptoms such quality, color, onset, duration, & any
precipitating or relieving factors
-Includes history or condition that may affect the current illness
*The patient has a history of...
-Includes the following elements
*Location*Quality*Severity*Duration*Timing*Context*Modifying factors*Associated
signs & symptoms
-Note the specific affected part being complained about
-Note the patient's presentation TODAY - any symptoms such as any worsening or
improvement
-Details in terms of exposure to sick contacts should be considered
-When a patient complaint/issue is resolved, this nees to be documented
-Obtain history regarding any stressors, stress at home/school/work
-document relevant dates in HPI portion as date of injury, date of accident, date
of onset
-Whatever is in the must be reflected under ROS, PE, Plan, and Diagnosis as
necessary
-Take the effort to obtain adequate follow up history when seeing a patient as a
follow up from a previous visit
-Consider reviewing the patient's current medications for any presenting symptoms
that may be brought about as a side effect of a medication
-Acknowledge ambulatory medication that the patients are taking
-Take the effort to reconcile medications
-Obtain adequate summation of a recent hospital visit when the patient presents
as a hospital or ER follow up.

>Review of Systems:
-Reiteration of the patient's complaints
-It must always include relevant aspects of presenting concerns
-Both positive & negative review of systems are to be thoroughly obtained
Use Positive/Negative for TESTS ONLY
Use Notable/Remarkable for pain/headaches/injury etc.

OBJECTIVE - Section documenting the measurable and objective data of the encounter
Physical Examination - vital signs obtained by provider
Laboratory Data - measures performed by the provider
- PE must address the patient's presenting concerns. It can be complete or
 focused
-Sign vs. Symptom
>A corresponding examination of the tender area of the body should
included in the physical examination
Laboratory Data: Urinalysis shows 2+ RBCs, 3+ WBCs, (+) nitrites
Diagnostic Data: EKG results show normal sinus rhythm
Procedure Performed: A partial nail avulsion was performed at the clinic
today...(details of the procedure)
-Be specific in which body part in being examined
-Document lab results, in particular the ones that are abnormal
-Add a heading after Neuro for Laboratory

ASSESSMENT - We are using ICD-10.

PLAN - Details the treatment plan or additional steps being taken to treat the
patient
-Includes additional testing & consultation with other provider