Clinical documentation
What each clinical documentation question is really asking, how to structure the answer, and where the marks are likely to sit.
SOAP note case study with ICD-10 coding
Clinical documentation
Analyse the week's case study and build a SOAP note covering disease prevention, health promotion and acute care, with scholarly evidence no older than five years, a scientific rationale for each nursing action, and the ICD-10 classification, in three to four pages.
Patient write-up marking criteria: where the points sit
Clinical documentation
The marking criteria for a patient write-up: identifying data, subjective and objective data, assessment, plan, internal consistency and clarity, with points attached to each. This guide works through where the marks actually sit, the banned documentation phrases, and the consistency criterion that catches otherwise sound notes.
Writing a Counseling Case Note in STIPS Format
Clinical documentation
Five sections, and each one has a distinct job. The Interventions section is where most notes go vague, and it is the one that makes documentation defensible.