Notes for medical purposes must be clear, accurate and concise. To help achieve this, some advice includes thinking about the facts, rather than opinions or suggestions. Use fewer words to get to the point quicker and keep phrases clear and understandable.
When your start writing notes, here are some requirements:
Most healthcare sectors use the SOAP (Subjective, Objective, Assessment and Plan) note format, which is probably the most common type of notes. It produces clear, comprehensive notes that follow a recognised format and doesn’t leave room for ambiguity or doubt.
Yes. Clinical paperwork such as SOAP notes and other forms can be considered to be part of a person’s legal medical records.