Overview
Three medical note templates are available by default - Basic SOAP, Simple SOAP, and Standard SOAP. The difference between the three is the level of detail in the "objective" section - the Standard SOAP is most detailed, and the Basic SOAP is least detailed. All medical note templates are available for use when checking in an appointment, under "History" in the patient's profile, or when converting an estimate to an invoice.
In addition to these three templates, you can create your own custom templates. When creating a custom medical note template, you may include any of over 400 pre-existing fields, as well as create your own custom fields. Medical note templates (like all templates) are managed in Settings.
Creating a Medical Note Template
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Click on "Settings"
Click on "Templates" and select "New Template"
Complete the form that appears, including selecting "Medical Note" as the type, and click "Save". You will be redirected to a blank medical note template.
On the left side of the screen, click on the arrow icon next to each section to expand that section.
Click the checkbox of the field you want to include in your template (these fields may include custom fields). Your selected field will appear on the right side of the screen
Provide any desired default text for the applicable fields, and drag-and-drop the fields into the desired order from the square icon next to the name of the field
Click "Save" button to save your changes
Time Saving Tip: Each field that is included in the template can also be pre-populated with default notes to speed up the note-taking process in your exams. Simply enter in text within the medical note template, and that text will always appear when that medical note is used.
You can create custom fields to include in your medical note templates. To learn more about custom fields, please see click here.
You can duplicate any existing medical note to save you time. From within the medical note template you wish to duplicate, select "Duplicate" from the headers.
Adding New Sections and Fields to a Patient's Specific Active Medical Note
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The needs for a particular patient's care and treatment may extend beyond the standardization that the general template provides, universally. To manage those cases, you can add new sections and fields to a patient's specific medical note on the fly. These edits will only take effect on that specific live medical note and not affect the main template.
Navigate to the patient's medical note
Click on the "Medical Note" tab and select "Add Section"
Click on the arrow next to the Section of interest to expand and view the subsections and various fields
Click the checkboxes to include the sections and fields of interest
Click "Save"
Workflow Tips: When working in a medical note for a patient, all fields in use will automatically save as you type. You will see a "Changes Saved" message periodically as you make edits to each field.
Multiple users can work within a medical note at the same time on a patient's record, in different fields.
Editing a Medical Note
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DaySmart Vet provides the ability to edit an existing unlocked medical note and these changes are auto-saved in real-time.
To edit an open medical note, simply navigate to the applicable medical note within the patient's profile and make the necessary changes.
Locking a Medical Note
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A locked medical note cannot be unlocked to ensure the integrity of the note's history. An amendment can be made if needed.
Lock a Medical Note Manually
Navigate to the applicable medical note
Click on "Lock Note" in the navigation bar
Confirm your intent to lock the note by typing lock in the field that is shown
Locking Medical Notes Automatically
Click on "Settings"
Within your configuration list, find "Lock Medical Notes" and select the edit button on the right
Select the option to "Automatically lock notes"
Specify the number of days after which the medical note should be locked
Select "Save" when done
Add an Amendment to a Locked Medical Note
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Navigate to the applicable medical note
Click on "Amendments" and select the option "Add Amendment"
Complete the form that appears and select "Save"
You can view the amendments from "View Amendments" under the "Amendments" tab
Once the amendment is added, the number of amendments present on the medical note will show on the amendments tab as well as the summary of that medical note in the patient profile.