clinical documentation

In this week’s show, John interviews Dr. Christian Zouain. Christian first appeared in Episode 77 to discuss how he landed his first job in Clinical Documentation Improvement (now usually referred to as Clinical Documentation Integrity).

During our interview, he shares his advice for landing your first job and mentions resources not discussed in his first appearance. He also describes how the industry has changed, and how to advance professionally in the industry.

He reminds listeners that it is possible to find a career in this field even if you have not completed residency. And he closes by inviting listeners to contact him for advice and to find out about open positions at his employer

You will find all of the links mentioned in the episode at nonclinicalphysicians.com/hospital-cdi-career/

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The most common and widely accepted format of clinical documentation is the SOAP note. It addresses the legal aspect of documenting the care you provide, but it also allows for consistency across providers, which is essential in healthcare. With all providers using the same format, it allows anyone reading it to follow along with your patient’s diagnosis and management plan. So how do you use it effectively?

Listen in this week to hear our top do’s and don’ts as they relate to using SOAP notes for clinical documentation. Anna and I are discussing what the SOAP note entails, what to include and avoid in your documentation, and our advice for how to keep refining your clinical documentation skills.

Get full show notes and more information here: https://blog.npreviews.com/dos-donts-clinical-documentation/