SOAP Charting

SOAPware derives its name from the SOAP format used for encounter documentation (i.e. Subjective, Objective, Assessment and Plan).

In SOAPware, the legacy format for encounters is for the Plan to be further divided into two (2) fields:

  1. Medications
  2. Follow-up

Subjective

Subjective

The history or information offered by the patient.

Objective

Objective

The findings discovered by clinical examination.

Assessment

Assessment

The diagnoses addressed during the encounter.

Plan

Plan

The plans for the patient's care going forward.

Medications

Medications

The medications prescribed.

Follow-up

Follow-up

The follow-up instructions.

Scroll to see the entire SOAP Note

Depending upon the size of the monitor used for the display and/or the amount of information contained within the SOAP Note fields, all the information within the six SOAP fields may not visible in a single view.  In order to view additional SOAP field information, click the Up or Down Arrows in the vertical scroll bar located on the right side of the SOAP Note workspace.

0 Comments

Add your comment

E-Mail me when someone replies to this comment