Creating a SOAP Note

This lesson discusses creating a SOAP Note.

Open the SOAP Note Chart Section

Open the SOAP note Chart Section

To create a new SOAP note, open the SOAP note chart section. Here, the user will be able to view previous visits as well as create, sign off, print, and reassign encounters.

Create Document

Create Document

Using the toolbar below the lower splitter bar, click the Create Document button.

Add Document Task

Add Document Task

When the user creates new patient documents, the Add Document Task window will appear. Tasks helps to manage reminders to keep tasks on track and improve productivity and quality of care.

This document task for a SOAP note will be associated with the encounter we are creating and can be set to have a particular action/status, indicating what needs to be addressed before the task is completed. The task can also have a reminder set, and can be assigned to anyone in the clinic.

The primary reason that we need to make sure to always track SOAP notes with a task associated is to make sure that the SOAP note encounter is signed off. If the action/status is set as Needs Review or Sign, the task will automatically be marked as completed and will be removed from the user's task list when the document is signed off.

For more on Tasks, see: Tasks List.

Using this window, the user can enter the information the user would like to include with the task, assign it to a user, set a due date and reminder, and choose an action/status. If the user clicks "Add", the task item will be added to the 'assigned to" person's task list. If the user clicks cancel, this will prevent SOAPware from creating a task item associated with this patient encounter.

Encounter Type for Meaningful Use

Encounter Type for Meaningful Use

SOAPware now has an added field for the encounter "Type" that is used for Meaningful Use purposes.  A user can designate if this was a "face to face" encounter, or a "non face to face encounter" when the "Add Document Task" window appears, or from the Document demographics area-found above the upper splitter bar.

By default, encounters will be flagged as "face to face" when they are created.  If a Template is being used, the user can set a default encounter Type within the Template.  See: Creating a Template for more information.

*Only encounters flagged as "Face to Face" will trigger the inclusion of a patient in the Meaningful Use/MIPS statistics for the reporting period selected by the provider.