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 chart. When documentation for the patient has been started in SOAP 2.0, the SOAP 2.0 Patient Records Page will load automatically.
- Then, select Create Daily Note. Remember, if you want to add a different type of note, such as a Case Note, select the Menu (...) button.
- 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.