What are the Common Formats Used in Standardized Documentation?
Several formats are commonly used in standardized documentation, including:
- SOAP Notes (Subjective, Objective, Assessment, Plan): This format helps organize information in a structured manner, making it easier to review and understand. - PIE Notes (Problem, Intervention, Evaluation): This format focuses on identifying specific problems, the interventions implemented, and the outcomes. - DAR Notes (Data, Action, Response): This format emphasizes the data collected, the actions taken, and the patient's response to those actions.
