A SOAP note (which stands for Subjective, Objective, Assessment, and Plan) is a document that's used by healthcare providers to create a patient's chart. It's especially useful for assessing, diagnosing, and treating patients.
SOAP Notes make it easy to capture visit details for each client, retrieve history, and view progress. Additionally, you can duplicate, add to, or edit client SOAP Notes in an easy fashion.
There are two types of SOAP notes you can add:
- SOAP notes and SOAP Notes Advanced, which contain more in-depth questions and an anatomy chart to pinpoint areas of treatment.
In this article, we will go over:
- Adding a SOAP Note to a Customer's Profile
- Viewing Completed SOAP Notes
- Controlling Employee Access to SOAP Notes
Let's get started!
How Do I Add a SOAP Note to a Customer's Profile?
1. Click Customers at the top of the screen.
2. Select the client.
3. Select SOAP.
4. Click the green Fill New Soap option. Then select the document you want to add to the client's profile. You can add SOAP Notes Advanced or SOAP Notes.
5. If you selected SOAP Notes Advanced, you can use the anatomy chart to pinpoint areas of treatment. Click Save when you're finished filling out the document.
Once you save a note, you'll be able to go back and review it. You can also edit the document.
6. If you selected SOAP Notes instead of SOAP Notes Advanced, fill out the document. Then click Save at the bottom of the screen when you're done.
Viewing Completed SOAP Notes
1. Go to the client's profile (Click Customers at the top of the screen--> Select the client). Then click the SOAP tab.
2. Select a date to see a SOAP note that was completed on a specific day.
3. Click Edit to edit a SOAP note that's been completed. Select Details to get more information about the completed document.
4. If you select the Details option, you'll be able to see when the client submitted the form. You can also see the Device and IP Address that was used as well as their Location.
5. If you select the Edit option, you'll be able to edit a SOAP note that's already been submitted. Click Save at the bottom of the screen when you're finished.
6. After saving the document, you'll see the date it was resubmitted in the client's profile.
Controlling Employee Access to SOAP Notes
To control an employee's access to the SOAP notes feature in your account, go to the access level you assigned to the employee (Click Settings --> Click Access levels --> Find the access level --> click the three dots on the right side --> select edit).
Find the Customer Notes, SOAP Notes & Forms access level. Click View to allow an employee to see all the notes you have created.
Click Modify if you want them to be able to edit the notes.
A green color means the option has been turned on. Click this link to learn more about access levels: Access Levels.