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EHR and tech companies are combining years of medical training and practice with data input (including vitalsigns, physicalexam findings, labs) to generate diagnoses and plans for patients via algorithms. Physicians are now even becoming holograms to interact with rural patients.
The SOAP note is typically specific to one therapy session and includes information such as: Subjective : Basic patient history and items reported by the patient, such as concerns, symptoms, medical history, and medications. Check out Valant’s clinical documentation features to learn more.
They are meant to maximize your educational experience while guaranteeing a high level of patientcare. General I expect you to be the primary caregiver for your patients. Of everyone on the team, you have the most time to spend with patients. Never hesitate to go back to gather more information from your patients.
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