What two types of notations are commonly used in patient documentation?

The two types of notations commonly used in patient documentation are SOAP notes and narrative notes.

SOAP notes provide a structured format for documenting patient information and stand for Subjective, Objective, Assessment, and Plan. This format helps healthcare professionals communicate clearly and systematically about a patient’s condition and treatment strategy. Subjective observations are the patient’s personal account of their symptoms, while Objective data is what the clinician observes through examinations and tests. The Assessment section synthesizes the subjective and objective data to provide a clinical judgment, and the Plan outlines the proposed management steps.

Narrative notes, on the other hand, are descriptive entries that allow for a more detailed and personal account of the patient's condition and care. This format can be more flexible, allowing clinicians to include detailed observations, thoughts, and treatment rationales in a chronological manner.

Together, these methods enhance the clarity and comprehensiveness of patient documentation, facilitating better communication between healthcare providers and improving patient care. The selection of these specific notations reflects the importance of both structured and flexible documentation in capturing the complete picture of patient management.