What are the best practices for documenting remote care encounters?

2 Follow the SOAP format

The second step for documenting remote care encounters is to use the SOAP format which stands for subjective, objective, assessment, and plan. This format helps to organize notes and capture essential information about the patient's condition, diagnosis, and treatment. Your SOAP notes should include the patient's chief complaint and history, symptoms, and expectations, as well as data collected from the patient such as vital signs or imaging studies. Additionally, you should include your clinical impression and differential diagnosis based on the subjective and objective data. Lastly, your notes should include treatment recommendations, prescriptions, referrals, follow-up instructions, and patient education.

4 Use clear and concise language

The fourth step is to use clear and concise language in your documentation, avoiding jargon, abbreviations, or slang. You should write in complete sentences, using proper grammar, spelling, and punctuation. You should also use consistent terminology and format throughout your documentation, following the standards and guidelines of your practice and specialty. You should avoid using vague or ambiguous terms, such as "normal", "good", or "fine", and instead use specific and measurable terms, such as "blood pressure 120/80", "pain level 3/10", or "range of motion 90 degrees".

5 Review and verify your documentation

The fifth step is to review and verify your documentation before finalizing and submitting it. You should check for any errors, omissions, or inconsistencies in your documentation, and make sure that it reflects the actual encounter and your clinical judgment. You should also ensure that your documentation is aligned with the coding and billing requirements of your payer and the services you provided. You should also obtain feedback from your peers or supervisors, if applicable, to improve your documentation skills and quality.

6 Secure and store your documentation

The sixth step is to secure and store your documentation in a safe and accessible place. You should use encryption, passwords, firewalls, and backups to protect your documentation from unauthorized access, loss, or damage. You should also follow the retention and disposal policies of your practice and the laws of your jurisdiction, regarding how long and how you should keep your documentation. You should also respect the patient's rights and preferences regarding their health information, such as access, correction, and deletion requests.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?