I’ve got a reputation at work, and I’m pretty happy about it. I’ve got 6 years less experience than my least experienced co-worker, far less continuing education, and not nearly the number of techniques under my belt. But my boss is in LOVE with my SOAP notes.
I’ll admit, it came from a place of insecurity, at first. I was the first person they’d ever hired who was so close to being fresh out of school. My first day, as I was typing up notes for my first client, the doctor poked his head in and reminded me to be as detailed as possible and “remember to use grown-up words for muscles and things.” He said it in a laughing way (I don’t think Dr. Harry could be condescending if he tried), but right then I said to myself, “I’ll show you grown-up,” and wrote the most detailed SOAP notes I could possibly muster. The location of every bruise, the full name of every muscle, end-of-massage feedback quoted verbatim, I put everything in.
Yeah, that surprised him.
I don’t do it because I’m insecure anymore. I do it because it’s helpful.
My clients have started asking for printouts of their SOAP notes to take with them to appointments with their acupuncturists, physical therapists, and primary care physicians. I can track bruising in my clients and line it up with their reported falls and injuries, to make sure I’m not causing any of it. I feel confident that, if I need to take a sick day, a colleague will have no problem knowing what my clients’ issues are. And I know that if, heaven forbid, a client’s medical records should ever be needed by a court of law, I will have record of EXACTLY what I have done, and why. There’s no substitute for that kind of peace of mind!
Come back tomorrow for tips on writing SOAP notes that make doctors swoon. Hope you enjoy!
photo credit: LuluP via photo pin cc