AAO-HNSF Certificate Program for Otolaryngology Personnel

will help to ensure complete entries in the medical record and point out common stumbling blocks found in documenting in patient’s charts.

“If it isn’t written down, you didn’t do it.”

CHARTING METHODS

There are several charting methods used by health care providers to help assure that appropriate information is included in the record. The SOAP method is a commonly used format to help promote complete and consistent entries.

SOAP format is as follows:

S= Subjective data: the patient’s description of their symptoms or condition.

O= Objective findings: the physician’s findings or observations about the patient.

A= Assessment: the physician’s assessment of the subjective complaints and objective findings.

P= Plan: the physician’s plan for current and future treatments.

Your notes should contain only objective documentation. Objective documentation supports your diagnosis and treatment plan. Subjective documentation is not supported by facts and can be open to interpretation.

Important points that must be included in every record:

• The patient’s name should be on every page in the record.

• The pages should be secured in chronological order.

• A problem list, current medication list, including the dosage and an allergy sticker, should be in the chart.

• Vital signs must be documented for each visit.

• Progress notes must be legible, complete, and signed and dated by the physician.

• Use only universally known abbreviations.

• Informed consent conversations including risks, benefits and treatment alternatives discussed and any associated forms noted in the chart.

• Discharge instructions including time and action specific instructions, for example, “if the pain is not better in 2 days, call me”.

All lab results need to be signed and dated by the physician. Abnormal lab results must be addressed. Follow-up actions taken or advice given to the patient should be clearly documented in the record. If no follow-up is documented in the medical record, the plaintiffs’ attorney will conclude that these results were either missed or ignored by the physician.