Daily Notes (SOAP 2.0)
Let’s review how to complete a Daily Note for your patient.
- When it’s time to document another note on your patient, navigate to the patient’s Records page in 1.0 and select Continue Documentation.
- Then, select Create Daily Note. Remember, if you want to add a different type of note, such as a Case Note, select the Secondary Actions Menu (...).
- Each section that has information entered will have a ‘Last updated’ date tag with the date of service from the previous note where this information was updated.
- Click on the subsection to review or edit the information as needed, then edit or Add to Note to carry forward the information as is.
- You must update or Add to Note in the Patient Presentation section.
- Subsections with pertinent information (like Diagnosis, Problems & Goals, etc.) will appear in Read-mode throughout the note. This allows you to quickly determine whether they need to be updated without taking up extra space.
- You must click Add to Note or edit the charges to successfully sign the note. Click here to learn more about the carry forward functionality of the Charge Summary section.
- When you’ve finished documenting, Sign the note.
Need to add a Daily Note to a Discharged case? Check out the workflow here.