SOAP notes

[JS14]

I was reminded the other day of why it is so important to keep good soap notes.

The women I rent from (you all remember THAT story :x ) got a subeno to supply notes for a client who had been in a car accident or something. This women keeps like no notes. Maybe one time but that isn't always certain either. Shame!

On the same topic, when you see clients over and over again and its always the same thing going on...... do you write new notes each session or just a quick.... "see last session notes"??? I admit to cheating like that sometimes if there was no change.

 

[mallos731]

I write, "Usual concerns, usual tx" on the "A" part (I use CARE notes), and just make the relevant symbols on the body drawings with S/M/L levels and changes if relevant.

Was your landlady getting insurance reimbursement? If so then of course the ins. co. will wonder why she has no notes, but a lawyer can subpoena anything hoping it exists, and if it simply doesn't exist she isn't in a bit of trouble for not having them. (Unless she is legally required to keep those notes by state law?) So if your notes are less than comprehensive, that doesn't necessarily mean you are in trouble. :

 

[karatoto74]

No it isn't a reimbursemant issue. I gathered that the client was seeking compensation due to the accident and is looking for any and all proof of injuries.

Will she get in trouble for not having them? Probably not. We have to state license here.