Create and Manage SOAP Notes

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

1. Open the Patient Manager, locate and select a patient.
2. Open the Patient Case for which you want to record a SOAP note.
3. Click the Soap Notes tab, then click [New SOAP Note] on the toolbar.
4. Optionally, assign the SOAP note to a different Patient Case by selecting from the Patient case drop-down list.
5. 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
6. 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
7. Click Open.
   Note: Depending on the selected template type, the system will open either a Rich Text Editor or a Predefined Form.
8. 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

1. Open the Appointment Book and double-click a checked-in appointment.
2. Click the SOAP Notes tab (on the bottom), click [New SOAP Note] on the toolbar.
3. Make sure the appropriate Case is selected in the Patient case field.
4. Follow the steps 4-7 in Create SOAP Note from Patient Case section above.

Edit SOAP Note from Patient Case

1. Open the Patient Manager, locate and select a patient.
2. Open the Patient Case for which you want to edit a SOAP note.
3. Click the Soap Notes tab, then select a SOAP note and click [Edit SOAP Note] on the toolbar.
4. Make changes, then save the Note.

Edit SOAP Note from Appointment

1. Open the Appointment Book and double-click a checked-in appointment.
2. Click the SOAP Notes tab (on the bottom), select a Note, then click [Edit SOAP Note] on the toolbar.
3. 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.

1. Open the Patient Manager, locate and select a patient.
2. Open the Patient Case for which you want to delete a SOAP note.
3. Click the Soap Notes tab, then check the box beside a SOAP note and click [Delete SOAP Note] on the toolbar.
4. 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.

1. Open the Appointment Book and double-click a checked-in appointment.
2. Click the SOAP Notes tab (on the bottom).
3. Check the box beside a SOAP note and click [Delete SOAP Note] on the toolbar.
4. Click Yes when prompted.