How Do You Document Patient Encounter In Vericle Soap Notes?
• Select Subjective to describe the patient’s current condition, usually beginning with the patient’s age and gender. It includes all pertinent and negative symptoms. Document how symptoms impact activities of daily living; Use the Standard SOAP format modified to SOAAP by adding an extra “A” for Activities of Daily Living. • Select Objective to include vital signs, findings from physical examinations, and results from laboratory tests. Document functional measurements (e.g., Range of Motion), comparison data, test results, co-morbidities, etc. to paint a picture of what is going on with the patient. • Select Assessment for a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. • Define the Plan as your “to do list” to treat the patient’s concerns. This should address each item of the differential diagnosis. Document goals for the patient and establish a reasonab
