Take a Tour of the Clinic 

The HUG Clinic has paper medical charts and documentation.  Faculty/Clinicians may use their own templates in the clinic for patient documentations (evaluations, daily notes, discharges, etc.); however, all documents need to be compliant with current state regulations.    Note: the HUG Clinic has templates, if requested.   

6-Point SOAP Note Checklist for patient charting:

1. Printed copy of daily documentation provided in medical chart for every visit

2. Patient chart is legible

3. Patient Name, MR # (found on patient chart), Date of Service rendered on top of initial page

4. SOAP Note Completion: Subjective, Objective, Assessment, Plan 

5. Changes to medical records need to be readable and initialed/dated by a licensed clinician.  

6. Sign and date bottom of documentation should include:

   • • Clinician/Faculty: Print name, title, current license number, & signature

     • Students: Print name, title (i.e. Student Physical Therapist Assistant), & signature

Patient charts and all supporting documents are part of the patient's official medical record.  These records may be sent to referring physician's and/or patient's at their request. 

 Please document professionally and accurately.   Student notes are reviewed as part of your clinical rotation and may be selected for documentation audits throughout the semester.