Explanation should include the concept that documentation is a written record of observations and actions related to a certain medical event. It should emphasize that documentation facilitates communication among healthcare professionals and other significant parties.
Process/Skill Questions:
- What is a subjective, objective, assessment and plan (SOAP) note? When should SOAP notes be written by certified/licensed allied healthcare professionals?
- What is involved in each of the components of a SOAP note?
- What are other types of documentation? What is the purpose of each?
- What parties may benefit from medical documentation? How might they benefit?