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SOAP: Objective

Add physical exams and edit, delete, and compare patient vitals.

Updated over 2 weeks ago

The Objective section is where you begin documenting concrete details from a patient’s physical exam. From this page, you can:

  • Add, edit, or delete vitals

  • Perform and record a physical exam

  • Compare multiple sets of vitals

Vitals

To log vitals, click + Add Vitals. You can enter the following:

  • Weight (in lb, kg, or g)

  • Temperature (in °F or °C) and temperature location

  • Pulse

  • Respiratory rate

  • Mucous membrane color and hydration status

  • Capillary refill time (CRT)

  • Attitude

  • Mentation

  • Blood pressure (if enabled): Systolic / Diastolic (MAP is calculated automatically)

  • Notes

Once saved, vitals appear at the top of the Objective section with a timestamp. If more than one set of vitals is entered, you can switch between them using the timestamp dropdown. These vitals can also be compared side-by-side using the Comparison Table described below.

Use the Did Not Obtain option if vitals were not recorded (fully or partially). These will be clearly marked when reviewing SOAPs or exporting medical records.

Blood Pressure

To enable blood pressure fields:

  1. Go to Admin -> Clinic Settings Settings tab

  2. Scroll to the SOAP section

  3. Turn on the toggle for Include Blood Pressure fields on vitals

Once enabled, blood pressure inputs will appear in the vitals form, and the MAP will be calculated based on systolic and diastolic values.

Physical Exams

Shepherd supports a variety of physical exam templates to match your practice’s workflow. Shepherd includes standard exam templates, and you can create your own custom versions as well. Learn more about Physical Exam Templates here.

To add an exam:

  1. Click Add Physical Exam

  2. Choose a template from your list

  3. Assign a supervising doctor

  4. Fill out the exam fields as needed

Once saved, the exam is added to the patient’s medical record and displayed in the Physical Exam section. If multiple exams are recorded during the visit, you can toggle between them using the dropdown in the upper-left corner of the section.

Body Map

To include a body map in your exam:

  1. Click Add Body Map at the bottom of the physical exam template

  2. Select a body map from the dropdown

  3. Mark up the map as needed

Comparison Table

The Comparison Table allows you to quickly view trends in vital signs by comparing multiple sets side by side.

You can track 10 or more sets of vitals (depending on your screen size), making it easier to detect changes over time at a glance.

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