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

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: