Document an Encounter
Q: How do I document an encounter?
1. Open the Patient Chart
Open the patients chart using the Chart Rack.
2. Open the SOAP Notes Chart Section
Click the SOAP Notes tab.
*Note: If the SOAP Notes tab is not visible in the chart, open it using the Chart Navigator.
3. Create a SOAP Note
See: Create a SOAP Note for help.
4. Document Subjective
To learn how to document the Subjective information, please see the following lessons:
5. Document Objective
To learn how to document the Objective information, please see the following lesson:
6. Document Assessment
To learn how to document the Assessment information, please see the following lesson:
7. Document Plan
To learn how to document the Plan information, please see the following lessons:
8. Document Medications
To learn how to document the Medications information, please see the following lesson:
9. ePrescribe
To learn how to ePrescribe, please see the following lesson:
10. Document Follow Up
To learn how to document the Follow Up information, please see the following lesson:
11. Print a Clinical Summary
To learn how to print a Clinical Summary, please see the following lesson:
12. Sign Off on the SOAPnote
To learn how to sign off on the SOAPnote, please see the following lesson: