After creating an initial note with the SOAP Wizard, subsequent note-taking becomes even smoother as the Wizard automatically carries over information from previous notes, ready for your review and necessary updates. Simply navigate to the patient's encounter to get started. 😄
Click below to explore each piece of an initial SOAP Note:Â
SUBJECTIVE
After opening up the encounter, you’ll start with the Subjective Wizard.Â
- The Subjective Wizard provides a brief summary of the patient's update, gathered from an automated survey based on where a patient is in their care plan.Â
No further action is required! Simply review the information before proceeding to the Assessment Wizard.Â
ASSESSMENT
- The diagnosis from the previous visit will populate, along with the essential indication.Â
- Since this is a subsequent SOAP note, all you need to do now is update the Diagnosis Status.Â
- Utilize the Plus/Minus options to indicate whether the diagnosis is significantly better (++), better (+), about the same (=), worse (-), or significantly worse (--).
Next, proceed to the Object Wizard!Â
OBJECTIVE
- All objective information that you noted from the prior visit carries over.Â
- Just click through the panels to make updates to the joint, range of motion, myofasical, orthopedic, and neurologic panels as necessary. Add details to any panel by clicking on the corresponding button.
- Similar to the Assessment Wizard, use the Plus/Minus options to quickly provide a status update for each panel.Â
After updating each panel and noting the status of each, proceed to the Plan Wizard!
PLAN
Note treatment and visit details within the Plan Wizard:Â
- Note the visit type under Evaluation & Management
- Add any Imaging & Tests
- Specify Treatments performed during the visit
- Add Modalities completed during the visit
- Document Supplements & SuppliesÂ
- Record prescribed and performed Rehab exercises.
Or, to make the same selections as from the previous note, click the SALT button. 🧂
Once you've recorded these visit-specific details, you're ready to move onto Schedule & Goals.
SCHEDULE & GOALS
Update any needed information to the Schedule & Goals section. Since you reviewed these details at the initial visit, you will be able to now move onto the SOAP output!Â
SOAP NOTE OUTPUT
- Review your SOAP note and make any necessary changes.Â
- Save and sign the note!Â
And That’s it— you’ve successfully created your follow-up SOAP note!! Way to GO!Â
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