Encounter SOAP Note
From OfficePracticum Help
OP users can choose between writing an encounter note in the comprehensive, or check-box, format, or the Encounter S.O.A.P. Note. The SOAP format is the classic medical note format, with text fields for "Subjective", "Objective", "Assessment", and "Plan".
|NOTE: The Encounter SOAP Note is available only in Versions 1780 and below. In Office Practicum 8 and higher, the Patient Encounter note replaces both the Comprehensive Encounter Note and Encounter SOAP Note as a means of documenting sick visits. Please see Patient Encounter Note, or see the section on Office Practicum 8 at the bottom of this page for information on this new note.|
Open the Patient Chart and choose a patient, then click the SOAP button in the central column.
NOTE: If the small, unmarked box in the upper left corner of the Patient Chart is checked, the comprehensive format will be the default format for Patient Encounter Notes. If you would like to have the option of writing both types of encounter notes, be sure that the box is unchecked.
 Writing an Encounter SOAP Note
- Open an Encounter SOAP Note.
- In the upper portion of the SOAP Note you will find a row of tabs. You can click on each tab to open different areas of the SOAP note, as listed and described in detail below.
 C.C./H.P.I/Hx tab
- If you are writing a note for a previous day's visit, click the next to the Date of Visit field and selecting a new date from the drop-down calendar. Otherwise, the date of visit will be entered as the current date.
- Enter the type of visit by clicking the button next to the Appointment Type field, and selecting an appointment type from the pop-up window.
- In the fields to the right, select the provider(s) involved in the visit. See Entering providers in a SOAP Note for more information.
- Enter your chief complaint (C.C.) and a history of the present illness (H.P.I.) in the large text field. You can type directly in the text field, or use the the Phrase Construction system by clicking the Use Phrase Construction (brown folder) icon to the immediate left of the C.C. field.
- Directly below the HPI text field is a display of the patient's chart notes.
- Scroll down to enter information about the physical exam. A series of text fields corresponds to the body areas examined. Click the "D" button to the right of each text field to apply a default statement of "normal" findings to the corresponding part of the body.
- Scroll further down to the "Plan" field to enter your assessment, treatment plan.
- Click the Enter Prescription button to open the Complete Medication List form, which displays the patient's medication chronology.
NOTE: Any prescriptions or tests you order will be simultaneously entered into the Plan field of your note. You do not have to make double entries.
- Click the Enter Diag. Tests button to make an entry into the Diagnostic Test Management table.
- You can also create tasks for the patient's Checklist by clicking Checklist/To Do.
 Vital Signs tab
- Enter vital signs and growth information in the Vital Signs and Growth Measurements table. The patient's Body Mass Index (BMI) is automatically calculated and all measurements are projected onto Pediatric Growth Curves.
- To view these growth curves, click on the Vital Signs Charts sub-tab.
 Procedures tab
Enter ICD-9 codes and billing information.
 Templates tab
Access or modify templates which you can use to speed up note-writing.
 Summary tab
- Preview the completed note. You can also:
- Enter additional information needed if the patient is being sent to the emergency room or a specialist.
- Print the Summary for parents by clicking the print icon in the upper right corner of the window, then clicking the print icon in the upper left corner of the Print Preview screen. For more information on printing a SOAP Note, see the Printing a SOAP Note section below.
 Graphic tab
Incorporate a photo or sketch into an encounter note.
 Archived Notes tab
View past encounter notes in the patient's record.
 Messages tab
View recent phone messages from the patient and family.
 Entering providers in a SOAP Note
In the Encounter SOAP Note, there are four ways to record the providers and other staff members involved in the patient visit. This may be useful, if not necessary, in many practices where RN's or Medical Assistants write notes under the supervision of an MD or another provider. For billing and auditing purposes, a Supervising Provider can be recorded.
To enter providers in an Encounter SOAP Note:
- Open an Encounter SOAP Note.
- In the upper right corner of the first tab (C.C/HPI/Hx) are four box fields:
- Entered by - By default, this field displays the name of the person logged into OP and entering the data. To change the name of the person entering the data, click the button and enter the new log-in.
- Service Prv (Service Provider) - Select the provider administering the services (e.g., a nurse administering a vaccine). The Service Provider does not appear in billing.
- Rendering Prv (Rendering Provider) - Select the provider that rendered the services. The Rendering Provider WILL appear in billing.
- Supervised by (Supervising Provider) - Select the MD or other provider that is required to 'sign off' on the work of the other provider. The Supervising Provider WILL appear in billing. Often, the rendering and supervising provider will be the same person.
- To enter a new provider in any of the above fields (except "Entered by"), click the button and select a provider name from the drop-down list.
- In some practices, one of the doctors has to co-sign a note written by a medical resident or paraprofessional. To indicate who cosigned a note, continue scrolling down the window to the very bottom, and locate the Chart Reviewed By field. Click the to select a provider name. Repeat in the field to the right, and select the date of review using the drop-down calendar.
- Click the button, located in the tool bar at the top of the window, to save your changes.
NOTE: If your practice has set up multiple locations and location groups, the Service Provider, Rendering Provider and Supervising Provider fields will be filled with only the staff members of the appropriate type who are members of the specified location.
 Printing a SOAP Note
In addition to printing a Summary of your notes (see Summary tab above), you can print the entire Encounter SOAP Note. Using this option, you can print out details of the visit along with your Chief Complaint, Diagnosis and other notes. You can also choose to include other information from the patient's chart, such as their Ongoing Problem List, past medical history, and allergies.
- When finished writing the SOAP Note, click the button in the upper left corner of the SOAP Note window. A Print Options window will open.
- To print notes from the visit only, along with patient information, click the radio button labeled Written or Updated ON the visit date.
- To print the day's notes and other chart information, click the radio button labeled Written or Updated ON or BEFORE the visit date.
- Click the check box below to include Current Meds (medications with a start date prior to the visit, or medications marked as ongoing).
- For either selection, a Print Preview screen will open. Click the button in the upper left corner to continue the printing process.
 Encounter notes in Office Practicum 8 and higher
As of Office Practicum 8, the Patient Encounter Note replaces both the Comprehensive Encounter Note and SOAP Note as a means of documenting sick visits. The Patient Encounter note encompasses both formats of the previous notes, and contains a wealth of new features, including:
- Reorganized, easier to read interface; all note sections displayed on a single Encounter Note tab, reducing need to toggle back and forth between tabs.
- Rich text capabilities in all text fields allow for advanced formatting, such as emboldening, italicizing or underlining text, or including bullet points to emphasize talking points.
- Plan section now includes access to the Order Worksheet, a new feature designed to organize and streamline your practice's workflow, and ensure that routine tasks are accomplished the same way for all patients at the same ages. See Order Worksheet for details.
- Vital Signs and Growth Measurements tables embedded in the Objective section, enabling you to document measurements directly in the encounter note.
- After writing a note, providers must now go to the Summary/Finalize tab to review the entire note and mark it as "Finalized". Finalizing a note effectively "seals" and archives the note in the patient's record, so as to ensure the security and integrity of medical information, and is a process required by the CCHIT.
- Once a note is finalized, it is no longer accessible by any providers or staff. Any additional information or corrections to the note may be entered as addenda to the note. All note finalizations are captured in the new Action Audit Trail.
Please see Patient Encounter Note for details.
 Helpful hints
- When writing sick visit notes, it is not required that you enter information in each of the possible fields to have a "complete" encounter note. Only those text fields that have been used will be displayed in the Summary sheet. There will be no gaps in the printed form.
- If you have a complicated patient visit and want to write a more detailed note than time allows, it is best not to hold up your practice's daily records archive. Having hundreds of unarchived notes and phone messages can slow up the system. Instead, you can:
- Write a brief summary or your impressions at the end of the visit, and mention that an addendum with more information will follow, then
- Write an "addendum" note, including additional information, then change the date to the date of the initial visit.
 Troubleshooting & Questions
- How do I invalidate an erroneous note that has been archived and billed to an insurance company?
- In order to invalidate an archived SOAP note you must:
- NOTE: the Encounter Comp. doesn't have the invalidate option.