Defensible Documentation in Home Health: Quantifiable Information

Course overview

The "O" portion of the SOAP note ("objective") is not a new concept when it comes to clinical documentation. Although the focus seems to be more on therapy than on nursing, all clinical documentation needs to contain a level of quantifiable information by which patient improvement or stabilization can be measured. The "A" portion ("assessment") goes hand in hand with the "O" as it is insufficient to just provide measures without analyzing the findings. This course will examine strategies for collecting and analyzing objective information and incorporating it into defensible documentation.