The SOAP Note chart tab is a dynamic chart tab in which data pulls for various chart tabs to create a formal visit note. Users may have various SOAP Note letters to choose from when creating a SOAP Note.
Navigating to the SOAP Note Chart Tab
- Begin by documenting all aspects of the visit. (For example, History, Vitals, Allergies, ROS, HPI, Exams, Problem List, Medications, Orders, Treatment Plan, Superbill, etc)
- Navigate to the SOAP Notes chart tab, the system will generate a SOAP Note based on the user's default SOAP Note letter.
- Users may choose to change the SOAP Note letter by selecting a new template from the first dropdown.In most cases, the SOAP Note type will generate on it's own based on the SOAP Note letter template settings.
- Once the user has reviewed the note and is ready to sign-off, navigate to the PIN box and enter their unique 4-digit pin. Click Save.
- For scheduled visits, a signed SOAP Note will be indicated using a green check mark on the appointment.
NOTE: Practices may use various terminology when labeling the final office note. (I.E. Progress Note, Visit Note, SOAP Note, etc)