Subjective Data         Objective Data         Assessment          Plan     and        Evaluation

The Evaluation piece has been added to the old method of just SOAP charting. It involves returning to check on your patient to document if the Plan portion was effective or not. This doesn’t not need to be part of your original note because it technically will take place later on and can be added as an addendum to your note if need be.

This is how it will look in Expanse when documenting a NOTE.

All Documentation Policies and Procedures have been updated in DMS, please take a moment to review them as well.