Case Notes (SOAP 2.0)

Case Notes allow you to record information that is not necessarily related to treatment, but should be part of the patient’s permanent medical record. Use this note type to provide an explanation: 

  • for missing work
  • a student-athlete note stating they can return to sports
  • or providing your opinion on the patient to a case manager.

Let’s review.

  1. Use the (1) [...] to select (2) Case Note.
  2. The Date of Note defaults to today. 
  3. Enter a document title and related comments.
  4. Sign the note. 
  5. The Title of the case note appears in the patient’s Notes section.

Forwarding Case Notes

Similar to other documentation, case notes can be forwarded to the supervising therapist as needed.

  1. Once the case note is complete, use the (1) Menu [...] to select (2) Forward.
  2. The Forward Note option functions the same as it does for standard documentation. Select the supervising therapist and click Apply. 
  3. The case note will have a Pending Cosignature status.
  4. The supervising therapist can access the case note from the Incomplete Cosign Docs alert on the Dashboard to verify and sign.