SOAP notes are used to document your Patient's Diagnosis and Treatment Plan.
Following the SOAP note structured approach allows you to keep track of your Patient's progress during their treatment & Keeps you compliant in case of an insurance audit. Also, because it is a universal format, your notes can be shared with other Healthcare Providers and easily be understood.
- In Primary Visit, Includes the patient's description of their Chief Complaint - Why are they seeing you?
- How it affects their activities of daily living
- History of current illness: Onset of symptoms, Provoking factors, Region of the body affected, Severity of symptoms, associated symptoms, duration of illness or symptoms
- Medical History: Past Medical History, Surgical History, Family History, Social History
- Current list of Medications: doses & frequency
- If utilizing Self Checkin, a Patient can enter their own Subjective Notes by use of questions asked during the self-check-in process.
- In Follow-up Visit, description of changes since the last visit. ie. Pain level with Pain Scale Ratings: same/better/worse according to patient & Patient's opinion on these(if any) changes
- Each Visit - Measurable Information you collect from the patient encounter
- Vital Signs: patient temperature, heart rate, blood pressure, respiratory rate & O2 saturation
- Findings from Physical Exam: Range of Motion, Tenderness, Patient's posture, GAIT(walking pattern), etc.
- Follow-Up Visit, record evidence that shows the patient is the same, better, or worse than the last visit.
- Based on Subjective & Objective notes, Provider thoughts regarding the Patient's Condition: Improvement or Decline
- Results of Diagnostic Tests, Xrays, Ultrasounds, and/or Scans
- Diagnosis - What is the problem?
- Prognosis - What is the Likely Outcome of this Illness?
- In Follow-up Visit, this area normally stays the same unless a new injury was developed, or the diagnosis has changed or the prognosis has changed
- Plan for Treatment received during the visit - Outlined Actions
- Any lab work ordered
- Adjustments performed
- Details of any Treatments or Therapies provided: Treatment name, location, muscle groups, duration & frequency, etc
- Suggested exercises or lifestyle changes
- This information usually stays the same until a Re-Exam has taken place
CoAction offers 3 other areas where Notes can be placed outside the scope of traditional SOAP notes:
- Any Notes separate from SOAP for Provider to record
- A medical narrative is a summary from a treating physician or other physicians outlining the patient's injuries, treatment to date, and future prognosis. Typically used as a compilation for personal injury, auto accident cases, etc. These notes are typically requested by Attorneys.
- This location is where your Initial Exam or Re-Exam findings/reporting will be housed to ensure these notes are separate from daily SOAP notes being recorded for the patient.
In CoAction, "Same as last treatment - SALT" is translated by making sure a Provider's SOAP notes are set to copy from Visit to Visit. You can find this area by going to Admin>Providers>Highlighting the Provider>Edit>SOAP Note Copying Tab:
Here, you will see a list of Note letters available. Check the appropriate boxes that should automatically copy from visit to visit>Save:
What are SOAP Note Macros?
SOAP Note Macros is the quickest way to document a patient's visit through button note-taking. The Buttons are housed within Categories of a Template and are Customizable/Editable to help manage & simplify your patient time efficiently.
What is a SOAP Note Macro Template?
This is a template of Macro buttons that already house information others have used in the past. If you are a new client, chances are, there is a default Macro template already uploaded to the Provider Usernames you provided in your Intake Paperwork. This template is found within any completed appointment>SOAP Note Macro Panel.
Please Click HERE for step-by-step information on customizing your SOAP Note Macro Template.
After you have your Macro Template customized to your need's, you can share your macro template with other Users or Providers in the clinic.
Please Click HERE for information on how to Share your SOAP Note Macro Template with others
**NOTE: Some providers have spent hours customizing & simplifying their SOAP Note Macro Templates and have given Support permission to share them with Clinics new to utilizing SOAP Note Macro's. Please reach out to Support for more information.
- Support Information -
If you have any questions or need assistance with this process please contact Support by:
Live chat: Click the 'Support Portal' button in your main toolbar (on left-hand side) within the software , click the green 'Support' box in bottom right of screen.
***This has the fastest response time***
Call or Text: 909-378-9514
Business Hours: Monday - Friday, 8am - 6pm CST