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SOAP notes must be completed at the end of every session. True or false?

1 Answer

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Final answer:

SOAP notes are required to be completed at the end of every session, aiding in the documentation of patient care and ensuring continuity and safety in healthcare settings. These notes include several checks, such as verifying procedure names and addressing equipment issues.

Step-by-step explanation:

The statement that SOAP notes must be completed at the end of every session is generally true. SOAP notes are a standardised method for healthcare professionals to document patient care in a clear, structured manner. The acronym stands for Subjective, Objective, Assessment, and Plan. In the process of documentation, several important components should be confirmed. For instance, a nurse or another healthcare team member should review out loud items such as the name of the procedure recorded, ensure that the needle, sponge, and instrument counts are complete, confirm the proper labeling of specimens including the patient's name, and address any issues with equipment. These steps help to ensure the accuracy snd safety of patient care and become a part of the patient's medical record. Updating SOAP notes at the end of each session helps keep patient information current and allows for continuity of care during subsequent healthcare interactions.

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