@giada23 I can see why you are doing what you do when it comes to documenting. I use to be a Medical Assistant Instructor and we did teach that we have to document what the patient states and to do it in their own words. However there is a limit to this. Do you remember the 6 C's of charting?
1.Client words 2. Clarity 3. Completeness 4. Consice 5. Chronological order 6. Confidentiality This is a good technique for keeping for notes short and sweet, but to the point and with the accurate information. Nurses can use this techniques as well. SOAP notes, though, is a documenting format that is used to get the nursing process on the way. This is by finding out the Subjective data (CC), Objective data (measureable data), Assessment (deciding what is wrong with the pt) and Planning (what to do). After this the ADOPIE is put into practice which is Assessment, Diagnosis, Outcome and Planning, Implementation and Evaluation. This is a mouth full. But each individual practice has the same general idea/format for documenting the same thing. For the part where you have to put what the patient says into a note, what nurses do is to paraphrase: write what the patient said, put it into a medical note, using proper medical terminology
and anything that stands out as important put into 'pt stated' and then use a "quote". I hope that this helps. Sorry, Im wordy too.