To navigate to the SOAP Summary, go to your Shepherd dashboard and click on a patient with an open SOAP. Alternatively, you can also navigate to a patient’s open SOAP by searching for them in Clients/Patients, opening their dashboard, and opening their SOAP (assuming they have one open).
The SOAP summary is a high-level view of the patient's current medical record. We've designed this section (as well as the 'Subjective' section) to be easy to fill out while you're checking the patient in. Let's take a look at what lives here.
Here’s what you’re able to do in the SOAP Summary:
Update SOAP status
Name the SOAP
Add a supervising doctor
Add a patient’s weight
Export the SOAP
Delete the SOAP
Create an estimate
View the SOAP’s activity log
Add addendum information
Updating the SOAP Status
Updating the SOAP status is a useful way of tracking which part of the visit the patient is in. To update the status of the SOAP, click on the dropdown next to ‘SOAP Summary’ in the top section. From there, you’ll be able to change the status to:
With the exception of ‘Locked,’ changing the status of the patient’s SOAP will affect which section of the dashboard they appear in (i.e. if a SOAP’s status is ‘In Review,’ that SOAP will appear in the ‘In Review’ section of your practice’s dashboard.
Locking a SOAP
Changing the SOAP to ‘Locked’ will close that particular record out to non-authorized users. This SOAP will now only be accessible through the patient’s dashboard, so don’t lock the SOAP until the patient’s visit is complete.
Unlocking the SOAP
With the correct permissions, you’re able to unlock a SOAP. To unlock a SOAP:
Open the SOAP you want to unlock (via the patient’s dashboard)
Change its status to ‘Active’ (or whichever status is most applicable)
Unlocking the SOAP is how you’ll be able to add any addendum information.
Naming the SOAP
Giving the SOAP a name is a good way to differentiate between different types of visits within the patient’s medical history. For example, if it’s a routine checkup with a 3 year rabies vaccine, you can name it something like ‘Annual checkup w/ 3 yr. Rabies: mm/dd/yy.’
Similarly, if it’s an atypical reason for a visit, it can be noted in the title (ex: ‘Checkup after eating 3 gingerbread houses: mm/dd/yy.’)
Note: the dates of these records will automatically be recorded, so they don’t necessarily need to be in the SOAP title.
Adding a Location
To make keeping track of patients as easy as possible, you can update their location whenever it changes in this dropdown.
Note: locations are a function of Admin and can be added, edited, and deleted from there.
Adding a Supervising Doctor
Similarly to the location, adding a supervising doctor is done through a dropdown.
There are multiple places within the SOAP to record the supervising doctor. So, if one doctor is responsible for the initial assessment and another finishes the visit with a prescription, both doctors will appear on the medical record.
Adding the Patient’s Weight
Since weighing a patient is one of the first things you’ll do for any visit, we’ve made this a quick and easy place to record. This will also affect things like estimates (if you’re going to create one).
Note: once recorded, the patient’s weight will be updated in the ‘Objective’ section of the SOAP. To add more vitals, click ‘Edit’ in the ‘Vitals’ section.
Creating an Estimate
Since this section as well as the ‘Subjective’ section of the patient’s SOAP are designed to be done while you’re checking in the patient (and while interacting with the client/authorized agent), we’ve added functionality to create an estimate on the spot.
This is especially handy when it’s a cut-and-dry reason for visit (spay/neuter, rabies vaccination, dental cleaning, etc.).
You’re able to create as many estimates within a record as you need, and once created, estimates can be edited or deleted at any point, so long as the SOAP remains open.
Viewing the SOAP Activity Log
The SOAP activity log keeps track of every change made within the SOAP—something that’s particularly important for any legal medical record. To view it, click the box to expand it.
Adding Addendum Information
Since adding addendum information should only be done after a SOAP has been locked, this can only be done by users with the correct permissions (see ‘Roles’ in Admin).
This functionality is particularly handy if you’re waiting on reports/results that can take a long time and are able to be added into the patient’s record retroactively.
Tip: We have a guide for unlocking SOAPs here.