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Thus far in our PTA Program, your exposure to medical documentation has been limited to something we referred to as the SOAP note. We used that type of note to document what you did with your ‘patient’ during your lab practicals. At this point, you may remember little more than what each letter stood for. Now, however, it is time to develop a deeper understanding of both medical documentation and the SOAP note. Let’s address the former item first.

To do so, we must answer the following questions:

• Why do we need to spend so much time and energy regarding medical documentation?
• Wouldn’t the patient do better if we spent more time treating them rather than spending time with documentation?

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