Documentation

Documentation refers to the detailed, accurate, and organized recording of patient information, clinical interactions, and services provided within a practice management setting. This includes creating and maintaining SOAP (Subjective, Objective, Assessment, Plan) notes, treatment plans, progress notes, and discharge summaries. Proper documentation is crucial not only for continuity of patient care but also to meet regulatory compliance and insurance requirements. Insurers often mandate comprehensive documentation to process and reimburse claims, and specific criteria can vary across different providers. Accurate documentation ensures transparency, enhances operational efficiency, and supports legal and ethical standards in healthcare practices.