Initial Visit vs. Routine SOAP Note: Are You Documenting Them Correctly?
Does your EHR make every patient visit look exactly the same?
That convenience could be creating a documentation problem.
In this KMC University HelpDesk episode, Dr. Erin Stubblefield explains the important differences between documenting the beginning of a new episode of care and documenting a routine chiropractic office visit.
You'll learn why "initial" doesn't necessarily mean a brand-new patient, what information should be captured when evaluating a new episode of care, how routine SOAP notes differ, and why relying too heavily on copy-and-paste EHR templates can leave important gaps in the clinical story.
Strong documentation isn't about making every note longer. It's about making sure every chart clearly supports the care provided.
Want to strengthen your documentation? Explore the KMC University Library or schedule a FREE Discovery Assessment to identify opportunities to improve your practice's documentation and compliance systems.
More episodes from "The KMC University Podcast"
Don't miss an episode of “The KMC University Podcast” and subscribe to it in the GetPodcast app.
