SOAP Notes Generator

Last Updated on Friday, 01 January 2010 11:18

The S.O.A.P note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by health care providers to write out notes in a patient's chart. Documenting patient encounters in the medical record is an integral part of practice work flow starting with patient appointment scheduling, to writing out notes, to medical billing.

Subjective component.

This describes the patient's current condition. The history or state of experienced symptoms are recorded. It will include pertinent and negative symptoms under review of body systems. Medical history, surgical history, family history, social history along with current medications and allergies are also recorded. If this is the first time a doctor is seeing a patient, they will take a History of Present Illness or HPI. You can enter data for the Subjective component in the main screen Patient Medical Record and History sub screens.

Objective component

The objective component includes: vital signs, findings from physical examinations, and results from laboratory tests and measurements, such as age and weight of the patient. You can enter data for the Objective component in the lab and clinical entry screens.

Assessment component

Is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. When used in a Problem Oriented Medical Record, relevant problem numbers or headings are included as subheadings in the assessment. You can enter data for the Assessment component in codification entry screens.

Plan component

Health care provider plans for the patient condition as described in Assessment component. This should address each item of the differential diagnosis. A note of what was discussed or advised with the patient as well as timings for further review or follow-up may also be included. You can enter data for the Plan component in Therapies and Appointment entry screens. Patient Status is retrieved from main Patient Medical Record screen.


Working with our SOAP notes software.

You can access the SOAP module from main Patient toolbar and top menu or from the right panel of main Patient Medical Record screen.

The data entry screen is divide in four sections corresponding to each SOAP component. Clicking the button the module retrieves and format data previously entered in E.M.R portion of software. You can also use templates created via the Report Template creator.

Finally you can open in preview mode a SOAP Note and print it or convert it in PDF format and attach it on Patient.

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