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Does anyone have any good insight or resources on documentation? What do you use? SOAP notes? Something else? I would like to be more organized and methodical in my notes so that I don't have to think so hard about it every time and so that it comes more easily to me. I also want to be thorough without spending half of my time on documentation.
 

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As a doula or midwife?
 

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For labor and postpartum notes I SOAP, for admission or new client notes I do a very thorough SOAP that includes current OB, OBGyn Hx, PMH/PSH, Fam Hx, and Soc Hx in my "S". I HATED SOAP notes while learning them, but they really do keep me organized and guide my assessment and plan. Routine prenatal visits I have a flowsheet and don't do a formal SOAP unless there is a problem I'm assessing more thoroughly. For labor I sometimes have to remind myself a SOAP can be quite brief or it's easy to get carried away and be charting for ages...
 
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