How To Create S.O.A.P Notes as a Practitioner?
Step 1
While on the Encounter page, you may click the "Clinical" tab.
You may create the SOAP Notes before, during, or right after the encounter has ended.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_cmdn2a.png)
Step 2
Then, click "SOAP Notes"
You may create the SOAP Notes before, during, or right after the encounter has ended.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1pvldmh.png)
Step 3
To add subjective for an encounter:
Click "Add" on the subjective section.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_137ykcc.png)
Select "subjective type".
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1sicto3.png)
Enter note.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_kydsav.png)
Click "Save".
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1aufigv.png)
Repeat this process to add more subjectives for an encounter.
Step 4
To add objective for an encounter:
Click "Add" on the objective section.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_134j9zr.png)
Select "objective type".
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_zm7y56.png)
For vital signs, select the type of vital sign.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_6gaobp.png)
Select the unit of measurement for the selected type of vital sign.
NOTE: The units of measurement for various vital signs vary depending on the type selected.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1gn5qmb.png)
Enter the value of the vital sign.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_auhso6.png)
Click "Save".
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1h2tab1.png)
For other types of objective, please provide the additional details displayed on the modal.
Repeat this process to add more objectives for an encounter.
Step 5
To add assessment for an encounter:
Click "Add" on the assessment section.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_jtpfu1.png)
Enter title for the assessment.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_8sdlq4.png)
Enter note.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1kwbpm8.png)
Select severity.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_2rubfn.png)
Select status.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1vmmvt4.png)
Search for your diagnosis using the built-in ICD-11 browser.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1h6dxsr.png)
Click "Save".
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_9wcbwg.png)
Repeat this process to add more assessments for an encounter.
Step 6
To add plan for an encounter.
Click "Add" on the plan section.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1oa6jk3.png)
Select assessment
NOTE: Before adding a plan for an encounter, it is essential to create an assessment first (See Step 5).
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_17vzser.png)
Select care plan.
NOTE: Care plan creation is only available on SeeYouDoc's TB Module.
If there is no available care plan, please select N/A.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1pl5wcf.png)
Enter a goal for the new plan.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_kwgney.png)
Enter note.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_14fe4dy.png)
Select status.
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1lb5us9.png)
Click "Save".
![](https://storage.crisp.chat/users/helpdesk/website/69886e7a5c80e400/image_1td1ywg.png)
Repeat this process to add more plans for an encounter.
Updated on: 05/08/2024
Thank you!