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SOAP Documentation System - Assignment Example

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The assignment "SOAP Documentation System" focuses on the critical analysis of the major issues in the SOAP (Subjective, Objective, Assessment, and Plan) documentation system that is used by physicians to document patient information systematically…
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SOAP Documentation System
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One legal advantage of SOAP is that there is documentation that ensures communication among different health professionals that may be involved in the treatment of that patient. This will prevent any misdiagnosis which may be blamed on one health worker only and which may lead to that health worker being sued. In case of anything goes wrong for the patient, all the health workers who were involved and integrated by the SOAP will be in trouble but that is rarely the case.

The other legal advantage of a SOAP documentation system is that since the documentation is in note form, the progress notes and all other information appear on one page, and hence no chance of ignoring part of the notes or not seeing all the notes as a result of missing pages as is common with other traditional documentation systems (Iyer, et al., 2006). This will ensure that non-maleficence and beneficence are promoted as no information which may cause harm to the patient will be left without being addressed.

This documentation system however has disadvantages too. One of the disadvantages is that every diagnosis is recorded in a different SOAP and this results in the redundancy of the work. This may lead to some health workers failing to record all the information which legally amounts to neglect which may cause harm and also ignore the non-maleficence code hence charges can be pressed against such a health worker.

This is the commonly used documentation system where the patient’s care and treatment information is recorded chronologically over the duration the patient is in a hospital or a health facility (Iyer, et al., 2006). One of its main legal advantages is that it is useful in emergencies to quickly collect information on patients’ health and the treatment interventions necessary. In case anything fails to be recorded or is misreported at that time, the health worker has legal protection as it was an emergency which is allowed by law.

The traditional narrative is the system that most health workers are taught in school and they, therefore, are competent with it. There are minimal chances of making mistakes in recording information about patients unlike other documentation systems they learn later on. If the health workers record the patient’s information effectively, no mistakes are bound to occur and hence minimal or no malpractice suits will be looming.

The system however has its disadvantage no matter how simple it is to use. The legal disadvantage is that the notes contain too much narrative that may prove to be too much or too cumbersome for a health professional or legal representative to get through and hence may choose only those areas they find important and leave the rest which may the important information to avoid the legal charges being pressed. The handwriting may also be illegible hence the wrong interpretation being made (Iyer, et al., 2006).

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