Must each SOAP note be signed and dated by the examiner?

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Signing and dating every SOAP note is essential to establish who wrote the entry and when it was created. This attribution provides accountability and creates a clear audit trail, which is crucial for legal protection, accurate billing, and seamless continuity of care. In practice, the examiner’s signature (or initials) and the date (and time if possible) should accompany each note, covering subjective, objective, assessment, and plan sections. Without a signed and dated entry, the record can be questioned about authorship and timing, potentially causing issues with reimbursement or legal defense. Modern electronic systems typically enforce this with automatic signatures and timestamps, but the underlying requirement remains: each SOAP note should be signed and dated by the examiner.