HOW TO USE NOTES/NARRATIVES

GENERATING A SOAP NOTE

Generating a SOAP Note:

This selection allows you to choose either a pre-set template for your SOAP Note, or to select Paragraph Selections that will allow you to build your own style of SOAP note. If you select the SOAP Full Template, it will then step you through making the necessary selections or answering the prompts that will complete this note ready for insertion into the patient’s file.

After you have selected your patient and to which claim this note belongs, click the “+” to add a new entry, then use the pull down arrow in the NOTE TYPE field to choose SOAP Notes.

Use the pull down list to choose the doctor responsible for this report.

In the Notes field itself, you may use a combination of free form typing and inserts to build your report/note/letter.

When you click on "Generate Note/Report" you will be able to scroll through your list of previously setup letters, paragraphs and phrases. What you will see in this list are all of the inserts that have been SELECTED to be part of these entries. Select the one you wish to use and insert this text into your note.

Now click on NEXT. This will start the automatic process. If a selection is needed, your Paragraph Selection will come up on the screen. Select the item that best suits this patient. To select more than one item, remember to hold down the CTRL key and click on each item you wish to use. The order in which they are selected is the order in which they will appear on your report. After you have made all of your selections, click on the button [insert text(s)] to add these selections to your note.

If this is a PROMPT, it will ask you to type in an appropriate response. Do so then again click on NEXT. Repeat this process until all selections and prompts have been handled.

When you have completed your Report/Note/Letter selections, you may either edit or print your note.

You may also export this report/note/letter to any Windows based word processor, if you want to merge it with your letterhead, or if you have special printing needs. There is a button on the bottom of the window called [Copy to Clipboard]. When you click on this button the report you just generated will be ready to be “pasted” into the work processor of your choice.

Printing SOAP Notes:

To print an individual note, select the patient and the claim to whom this note belongs. Use the Show List of Records Icon to see all of the notes and reports that have been generated for this patient.

Find the SOAP note that you wish to print and double click ( or click on Select Record or click on the X to close the selection record) and pull up this note. Now click on print at the bottom of the screen.

To print a range of SOAP notes for a patient, select the patient and the claim to whom this note belongs. At the bottom of the window you have a button called [Select Notes]. Hold down the CTRL key and click on all notes that you wish to see on this report (or click on the Select All Notes box if you wish to print all of the SOAP notes for this claim). Now click on print at the bottom of the screen.

To View All Notes

To view all notes for this claim regardless of the type of note, click on the Show a List of Records. This will display all notes for this claim. You will be able to see in the first column (Claim Cat.) what type of note this is.