The Struggle between efficiency and adhering to the legal and medical documentation guidelines.

Due to the electronic health records (EHRs) and documentation guidelines, physicians struggle to complete their notes promptly. While templates can make documenting care in the EHR more structured and efficient, challenges arise when physicians use templates that auto-populate much of the information within the patient encounter as documented in the EHR. Some of that information may need to be more relevant or currently applicable.

Downfalls of using clinical documentation templates

Clinical documentation templates are predesigned forms that healthcare providers can use to document patient encounters. While templates can make documenting care in the EHR more structured and efficient, there are several challenges associated with their use.

First, templates can lead to over-documentation and cloning of notes, making it difficult to determine what is happening with the patient. Second, templates can lead to a need for more specificity and detail in the documentation. Third, templates can be time-consuming to create and maintain. Fourth, templates can be inflexible and may not allow for customization. Finally, challenges arise when physicians use templates that auto-populate much of the information within the patient encounter as documented in the EHR. Some of that information may need to be more relevant or currently applicable.

“Templates can lead to over-documentation and cloning of notes, making it difficult to determine what is happening with the patient.”

Despite these challenges, clinical documentation templates remain popular. Healthcare providers should consider using SOAP clinical documentation tools to mitigate some of these challenges.

Benefits of using SOAP clinical documentation tools

SOAP notes are a structured format for documenting patient encounters used by healthcare providers for decades. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Each note section is designed to capture specific information about the patient encounter.

The subjective section of the note captures the patient’s chief complaint and any other subjective information that the patient provides. The objective section captures objective data such as vital signs, physical exam findings, and lab results. The assessment section captures the provider’s assessment of the patient’s condition based on subjective and objective data. Finally, the plan section outlines the provider’s plan for managing the patient’s condition.

There are several benefits to using SOAP notes:

1. They provide a structured format for documenting patient encounters, ensuring that all relevant information is included in the patient’s medical record.
2. They help providers to better manage their time and workload by providing a clear framework for documenting patient encounters.
3. They can help reduce errors and improve patient safety by ensuring that all relevant information is captured in the medical record.
4. They can help providers to better track patient outcomes by providing a clear record of the patient’s condition over time.

Five things that must be included in a SOAP clinical documentation tool

1. Patient demographics and identification information.
2. A summary of the patient’s medical history.
3. An overview of the patient’s current condition and treatment plan.
4. Documentation of all patient encounters, including progress notes, lab results, and imaging studies.
5. A mechanism for tracking and managing patient outcomes.

TAPTYPE is an advanced patient assessment and documentation tool for physicians. It empowers healthcare teams and entities with a tool
to standardize note-taking across their interdisciplinary teams.TAPTYPE allows doctors to fill out their patient’s encounter notes, isolating the need for writing a single word. This produces complete and neat notes that are medically and legally compliant. It also has add-on features such as Share Questionnaire and Terminal Access. It saves 79.2% of your documentation time compared to traditional note-taking methods, while producing better clinical outcomes.

 “TAPTYPE saves 79.2% of your documentation time compared to traditional note-taking methods.”

Ready to spend more time with your patients and less time on documentation? Try TAPTYPE