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Documentation completeness check

The Documentation check looks at whether the standard parts of your note are there and agree with each other. It is not related to coding level or payment, and nothing is added to your note unless you add it.

ForCliniciansUpdated

Where to find it

It sits above the note on the Note tab, folded to a short line such as “4 items to review · 1 possible inconsistency”. It shows counts only, never a score. Press Review items to open it.

The Documentation check panel opened: a possible inconsistency in Plan about a medicine dose, and items for History of present illness and Assessment, each with a Review in link, Show all 4 items, and the line Documentation completeness only. Not related to coding level or payment.
Each item names the section it’s about. Sample visit.

What it lists

Kind of itemWhat it meansYour choices
Possible inconsistencyTwo parts of the note may disagree. Check which one is right.Fix in note · Note is correct · Not applicable · Check is wrong
Missing or unspecific detailA standard detail may be missing. Add it only if it was discussed in the visit.Add to note · Already documented · Not discussed · Not applicable · Check is wrong
Marked linesLines the note writer used where the visit didn’t cover something or the audio was unclear, such as “Not stated in this visit.”Fill in

Answer an item

  1. Press Review in and the section name. The item also sits under its own section in the note.
  2. Pick a response. One tap, no reason needed. Add to note or Fix in note puts your cursor in that section so you can type; nothing is written for you.
  3. Press Undo to change a response.

After you edit the note

If you change the note after the check ran, it says “The note changed after this check”. Press Recheck to see what’s still open. If the check didn’t run for a note, press Run check; your draft is ready either way.

Nothing here blocks you. You can copy, mark reviewed or sign the note without answering any item.

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Email support@soapsuds.io or send us a message. Please don't include patient names or details; the visit date and time is enough for us to find it.

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