Create and Update Patient SOAP or Subjective, Objective, Assessment, and Treatment Plan in an Encounter
1. Click on the Notes Tab in an Encounter
2. Enter in Subjective Details
Enter in the Subjective note for the patient
Clicking anywhere else will automatically save the information followed by an automated time stamp of the time it was last edited
Clicking on the (-) sign will toggle and shrink the data for ease of readability moving forward and vice versa clicking on the (+) sign will toggle and expand the data
3. Enter in Objective
4. Enter in Assessment followed by ICD-10 when applicable
5. Add ICD-10 Code(s)
- Search for an ICD-10 code, enter the letter along with the number or key words in the description in box 1
- When a code is selected ADD it to the list. Multiple codes can be selected
- Use ADD CHECKED or REMOVE CHECKED if you are selecting in bulk
6. Enter in Treatment Plan
- Enter in treatment plan
- Decide if this patient requires a follow. An answer of "yes" will prompt the below questions
- Enter in the Date of Maximum Medical Improvement anticipated
- Enter in the expected Follow-up Date
- Enter in the reason for the change in MMI Date when applicable
7. If selecting 'No' for follow up
If selecting No, select the disposition
8. Select New Treatment or Orders
- Add a name for the Treatment Type, if applicable but not required
- Add the Treatment Name which is Required
- Add Frequency or the Duration
- Include the ICD Code
- Include the CPT Code, if applicable but not required
- Click on ADD TREATMENT when finished
- Selecting or Deselecting the check box allows you to choose from the options below
- Make an RFA from the selected
- or Delete the selected
- The SOAP NOTE option is used to save and view the current SOAP note generated
9. Add Orders
- Input any orders when applicable
- Add or view order request
- Delete when needed
