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. 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. Medical note templates (like all templates) are managed in Settings.
To create a medical note template:
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.
Click "save" button to save your changes
You can create custom fields to include in your medical note templates. To learn more about custom fields, please see Working with Custom Fields.
To duplicate an existing medical note template:
Click on Settings
Click on "templates" and select "view medical notes"
Click on the gear icon for template you wish to duplicate, and select "duplicate"
Complete the form that appears, and click "save"
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.
To add new sections and fields to a patient's specific active medical note:
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
All fields when in use on a patient record 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 patients record, in different fields.