Concept of OCMU & SOAP lucidly explained

Dr.Anup Marar explained that records should be objective, consistent, meaningful and useable (OCMU). Moreover the need of all doctors, nurses to regularly write SOAP notes (Subjective, Objective, Assessment, Plan) after each examination and round is desired as archives and records management share a simple goal of providing for organizational & individual accountability. Accountability depends on being able to demonstrate managed access to information which is important for reasons of ongoing need or future evidence, from the time of its creation.
Document everything you do; as it is your documentation which is only going to be of any use later, he added. He conveyed that at OCHRI nobody is expected to follow oral instructions. There has to be an accountability of directives either upwards, downwards or in sideways communication. This maintains answerability and transparency.








