SOAPware DocumentationSOAPware FAQ'sFAQ's Summary/SOAPnote SpecificQ: How do you document phone calls and/or e-mail messages received from patients?

Q: How do you document phone calls and/or e-mail messages received from patients?

A: Phone calls for medication refills, email messages, test results or just patient triage phone calls, should be documented in the SOAP Note chart section of a patients chart.  This allows the patient documentation to be signed off, preventing alteration of patient information. Documentation relating to a patient phone call, plan, any medications prescribed, and follow up, can be documented in one centralized area area.