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.

Step 2

Then, click "SOAP Notes"

You may create the SOAP Notes before, during, or right after the encounter has ended.

Step 3

To add subjective for an encounter:

Click "Add" on the subjective section.



Select "subjective type".



Enter note.



Click "Save".



Repeat this process to add more subjectives for an encounter.

Step 4

To add objective for an encounter:

Click "Add" on the objective section.



Select "objective type".



For vital signs, select the type of vital sign.



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.



Enter the value of the vital sign.



Click "Save".



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.



Enter title for the assessment.



Enter note.



Select severity.



Select status.



Search for your diagnosis using the built-in ICD-11 browser.



Click "Save".



Repeat this process to add more assessments for an encounter.

Step 6

To add plan for an encounter.

Click "Add" on the plan section.



Select assessment

NOTE: Before adding a plan for an encounter, it is essential to create an assessment first (See Step 5).



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.



Enter a goal for the new plan.



Enter note.



Select status.



Click "Save".



Repeat this process to add more plans for an encounter.

Updated on: 05/08/2024