BY DEAN MASON , C . PED ., BOCO , CO
Documentation is critical to the profession and your practice and it can save you should there ever be a challenge to your treatment . Remember , complete and accurate charting , along with note taking is essential , not only to protect you , but to remind you each time you see each patient of the finer details that our brains might have replaced with what we had for lunch . As in the law , if it ’ s not on paper , it doesn ’ t exist .
So , what constitutes good documentation ? That answer can be as varied as those who practice Pedorthics . Besides a few basics that are required by law and our insurance sources , the rest should be dictated by common sense and reason . When we see a patient for fifteen minutes , it can take us much longer to document all the details of the case . Yet , these notes are the most important details to maintain an accurate record of what was done , what issues were discussed , your findings , treatment , as well as follow-up with the patient and the physician , etc .
Your basic mode of documentation is a patient chart , and charts should be maintained by every medical provider as a means of a history of our involvement with a particular patient . Some use the subjective , objective , assessment and plan ( SOAP ) note methods and others just wing it , but my rule of thumb is to follow the rules and keep it as simple as possible .
Photo by : © Shutterstock . com / Dinga
12 Pedorthic Footcare Association www . pedorthics . org