# Clinical Documentation Guidelines

## SOAP Note Standards

### Subjective (S)
**Purpose**: Document patient-reported information

**Required Elements**:
- Chief complaint (CC)
- History of present illness (HPI)
  - Onset
  - Duration
  - Character
  - Aggravating/Alleviating factors
  - Associated symptoms
  - Severity (1-10 scale)
- Review of systems (ROS) - relevant
- Past medical history (PMH)
- Medications
- Allergies
- Social history (relevant)
- Family history (relevant)

**Writing Tips**:
- Use patient's own words when appropriate
- Document negative findings with "denies"
- Include temporal information

### Objective (O)
**Purpose**: Document observable, measurable data

**Required Elements**:
- Vital signs (with time)
- Physical examination findings
- Laboratory results
- Imaging results
- Other diagnostic data

**Writing Tips**:
- Use standard medical terminology
- Include measurements and values
- Note "WNL" (Within Normal Limits) for normal findings
- Describe abnormal findings specifically

### Assessment (A)
**Purpose**: Clinical interpretation and diagnosis

**Required Elements**:
- Primary diagnosis
- Differential diagnoses
- Problem list
- Status/changes from previous encounters

**Writing Tips**:
- Be specific with diagnoses
- Include diagnostic reasoning
- Address all problems identified
- Note stability/instability

### Plan (P)
**Purpose**: Treatment and management strategy

**Required Elements**:
- Medications (drug, dose, route, frequency)
- Procedures/tests ordered
- Consultations/referrals
- Patient education
- Follow-up plan

**Writing Tips**:
- Be specific with dosing
- Include patient instructions
- Specify timeframe for follow-up
- Document informed consent

## Medical Documentation Principles

### 1. Clarity
- Use unambiguous language
- Avoid abbreviations that could be misinterpreted
- Write legibly (if handwritten)

### 2. Completeness
- Document all relevant information
- Include negative findings
- Record all decisions and reasoning

### 3. Timeliness
- Document during or immediately after encounter
- Include date and time for all entries

### 4. Accuracy
- Verify all facts before recording
- Correct errors properly (single line through, initial, date)
- Never alter records after the fact

### 5. Objectivity
- Distinguish fact from opinion
- Quote patient when documenting subjective information

## Legal Considerations

- All entries must be dated and signed
- Use permanent ink for handwritten notes
- Never leave blank spaces
- Document informed consent discussions
- Include patient non-compliance if applicable

## Quality Metrics

Effective SOAP notes should be:
- **Specific**: Avoid vague terms like "good" or "normal"
- **Measurable**: Include quantifiable data
- **Actionable**: Clear next steps
- **Relevant**: Focus on pertinent information
- **Time-bound**: Include timelines for follow-up
