Documentation

Your state may require specific documentation when prescribing medications for ED.  Consult your state laws to ensure that you are compliant.  One approach is to use a SOAP note format.  A standard SOAP (Subjective, Objective, Assessment, Plan) note is described below.

SOAP Note Format

Subjective

All pertinent information that comes from the patient

Objective

Relevant physical exam findings and vitals

Assessment/Plan

Your diagnosis and what supports that diagnosis,

Plan

Plan of action (medication given or the patient was referred), disease and medication specific education given to the patient, and follow up plan

 

Close Bitnami banner
Bitnami