This article will help you create and manage SOAP notes. The following steps can be done from either an Appointment or from a Patient Case. SOAP notes may be entered in one of two formats:
- a standardized form with sections for observations, subjective, and objective findings
- a rich text format file
Create SOAP Note from Patient Case
- Open the Patient Manager, locate and select a patient.
- Open the Patient Case for which you want to record a SOAP note.
- Click the Soap Notes tab, then click [New SOAP Note] on the toolbar.
- Optionally, assign the SOAP note to a different Patient Case by selecting from the Patient case drop-down list.
- To create the note using a:
- Predefined Form, from the Template type drop-down list, select System
- Rich Text Editor, from the Template type drop-down list, select Custom
- To start from scratch, select Blank from the Duplicate from drop-down list.
Tip: To base a note on a:- previous one, from the Duplicate from drop-down list, select Previous, then select from the list of previous notes
- preset, from the Duplicate from drop-down list, select Preset, then select from the list of presets
- Click Open.
Note: Depending on the selected template type, the system will open either a Rich Text Editor or a Predefined Form. - Once completed, save the Note.
Note: When saving a rich text document you will be prompted to enter document properties such as Document Name, Visit Number and Description.
Create SOAP Note from Appointment
- Open the Appointment Book and double-click a checked-in appointment.
- Click the SOAP Notes tab (on the bottom), click [New SOAP Note] on the toolbar.
- Make sure the appropriate Case is selected in the Patient case field.
- Follow the steps 4-7 in Create SOAP Note from Patient Case section above.
Edit SOAP Note from Patient Case
- Open the Patient Manager, locate and select a patient.
- Open the Patient Case for which you want to edit a SOAP note.
- Click the Soap Notes tab, then select a SOAP note and click [Edit SOAP Note] on the toolbar.
- Make changes, then save the Note.
Edit SOAP Note from Appointment
- Open the Appointment Book and double-click a checked-in appointment.
- Click the SOAP Notes tab (on the bottom), select a Note, then click [Edit SOAP Note] on the toolbar.
- Make changes, then save the Note.
Delete SOAP Note from Patient Case
Note: You are required to enter user password and have appropriate permissions in order to delete SOAP notes.
- Open the Patient Manager, locate and select a patient.
- Open the Patient Case for which you want to delete a SOAP note.
- Click the Soap Notes tab, then check the box beside a SOAP note and click [Delete SOAP Note] on the toolbar.
- Click Yes when prompted.
Delete SOAP Note from Appointment
Note: You are required to enter user password and have appropriate permissions in order to delete SOAP notes.
- Open the Appointment Book and double-click a checked-in appointment.
- Click the SOAP Notes tab (on the bottom).
- Check the box beside a SOAP note and click [Delete SOAP Note] on the toolbar.
- Click Yes when prompted.