18 Mar How long should it take to write SOAP notes?

Most medical professionals at some point have spent uncounted hours writing and re-writing clinical notes. The move from paper to electronic health records has left many clinicians spending more time writing, filing, and updating their clinical notes than ever.[1]

Many clinicians actually spend more time on clinical notes and administration than with their patients. Much of that time is spent re-reading and writing clinical notes, which many claim have grown longer, less informative, and less useful for patient care over time.[2]

Want to spend less time but write better notes?

How long does it take you to prepare for your patient, take clinical notes and update your patient’s health record?

If each patient requires 15 minutes of note taking and administration, and you see on average 20 patients per week; you are spending 5 hours per week – or 20 hours per month, just writing clinical notes. If you have a number of complex cases and patients that require extended sessions or consultations with other professionals, your note taking may take even longer.

If this sounds familiar, it’s time to adopt a new method that will save you time and money.

When was the last time you audited your clinical notes?

Regardless of whether your clinical notes are electronic or paper, they are an integral component in good professional practice and the delivery of quality healthcare. Always keep in mind that clinical notes may potentially be requested by the patient, another health professional or regulatory body.

Conducting regular and thorough audits of clinical notes is best practice for ensuring all files are as in-depth and up to date with information such as:

• Patient history and clinical details
• Dates that the service was initiated or referred, including written and telephone correspondence
• Patient appointment no-show, cancellation or late arrival
• Service location if other than the primary place of practice
• Details of supervision, and coordination with other health professionals
• Patient assessment and intervention plan
• Patient progress toward established goals
• Details of any aids or appliances required
• Clinical judgements and conclusions
• Patient written informed consent

If you are over spending hours on clinical notes, there is another way.

Try ClinikNote for 30 days – for free!

ClinikNote software supports:

• Taking live notes on your iPad with voice, photo and drawing functions
• Desktop, iPad and web app workflows
• Data encryption that meets HIPPA and GDPR compliance
• Electronic streamlined Consent and Intake Forms for new clients
• Existing clinical templates or use the inbuilt template builder to digitise your own
• Automated administration checks – never miss a task
• You to run your practice, your way.

[1] Rule A, Bedrick S, Chiang MF, Hribar MR. Length and Redundancy of Outpatient Progress Notes Across a Decade at an Academic Medical Center. JAMA Netw Open. 2021;4(7):e2115334. doi:10.1001/jamanetworkopen.2021.15334

[2] Jones SS, Rudin RS, Perry T, Shekelle PG. Health information technology: an updated systematic review with a focus on meaningful use. Ann Intern Med. 2014;160(1):48-54. doi:10.7326/M13-1531