SOAP Notes

What are SOAP Notes?
SOAP Notes is where users can enter the progress notes for the patient after the encounter is completed. Users have the ability to free form type into the note, use the quick pick functionality to add pre-defined phrases, words, and sentences to the note, and use the menus to quickly add information captured during the patient encounter.

From the Patient Dashboard:

The SOAP Notes screen will be displayed. The SOAP Headers will be displayed by default into the SOAP Note.

Previous Encounter Date - If a SOAP Note has been previously entered for the patient, clicking on the drop-down list will display the list of SOAP Notes and the applicable encounter date.

Encounter Date - This date will default to the same date as the appointment schedule on the left hand side of the screen.

Toolbar - The options available on the toolbar are similar to those that are used in Microsoft Word.

          • Left click on either of the 4 blue bars to display the patient items in that area.

Once the applicable information has been defaulted into the SOAP Note, users can then add additional information by typing in the information directly into the SOAP Note, or by selecting information from the Quick Picks section. For information on using Quick Picks, go to Quick Picks.

[  ] Completed - Select this checkbox if the SOAP Note is completed and does not require any additional information to be added. NOTE:  Any SOAP Note that is saved and is not marked as completed will be displayed on the provider's dashboard as Open. For instructions on using the provider dashboard, go to Provider Dashboard.

Audit/SignOff - Users now have the ability to view an audit log for SOAP notes as well as to be able to enter a Sign Off (and Secondary Sign Off) if needed. Click on Audit/SignOff to change the toolbar display.

Sign Off Status:  Required - Click on this link to open the sign off screen.

Buttons

- Select this button to display the list of menu options.

Help - Select this option (or hit the F1 key on any screen) to display the online User Manual.

Window Print - Select this option to print out a copy of the information in the window.

User Settings - Select this option to open the User Settings screen. For instructions on the User Settings screen, go to User Settings.

Screen Settings - Select this option to update the Screen Settings for SOAP notes. For instructions on the Screen settings, go to Screen.

New - Select this option to clear the screen for entry of new information.

Print - Select this option to print the details on the screen.

Close Menu - Select this option to close the Menu list.

- Select this option to clear the screen for entry of new information.

- Select this option to print the details on the screen.

- Select this button to save the changes and close the SOAP Notes screen.

- Select this button cancel out of the SOAP Notes screen without saving any changes.

- Select this button to save the changes to the SOAP Notes screen (the SOAP Notes screen will remain open).

 

Document Links
Quick Picks

Provider Dashboard

User Settings

Screen