To navigate to the ‘Assessment’ section:

  1. From the dashboard, click on a patient with an open SOAP

  2. Once open, click the ‘A’ at the top of the record.

Note: you can also get there through searching for a patient in ‘Clients/Patients’ and opening their SOAP from the patient dashboard.

We have a walkthrough for this section, as well as this written guide.

Overview:

The 'Assessment' section of the SOAP is where the doctor can start taking notes and adding different pieces to the patient's medical record. You’re able to:

  • Create a problem list

  • Give a true diagnosis

  • Add/remove chronic conditions

  • Make an assessment

  • Give a prognosis

  • Upload images/documents for

Note: Everything in the ‘Problem List,’ ‘Diagnosis,’ and ‘Chronic’ sections pulls from the ‘Diagnoses’ section of Admin. You can view these by opening Admin and then clicking ‘Diagnoses.’

Creating a Problem List

To add a problem to the list, start typing and select it from the dropdown. You can add as many problems as are relevant to the patient.

Give a Diagnosis

The ‘Diagnosis’ section is for a true diagnosis for the patient. You’ll be able to add multiple diagnoses to a patient.

Tip: if any diagnosis has discharge information attached to it in Admin, adding it to their treatment plan will automatically add that discharge information to the patient’s medical record. To learn how to add discharge information to a diagnosis, check out our ‘Diagnosis’ walkthrough.

Note Chronic Conditions

If the patient appears to have any chronic ailments, you’ll be able to select them here, as well.

When you add a chronic condition, you’ll have to add a note as to why you believe the condition is chronic. These conditions will also populate on the patient’s dashboard and transfer through any subsequent SOAPs the patient has (until the condition is resolved).

To remove a chronic condition from a patient’s record, click the ‘x’ by the condition name.

Make an Assessment

This is an expandable, freeform field that allows the physician to further explain the patient’s condition. As with any medical record, it’s all about giving insight into the rationale behind decisions—this one, obviously for diagnoses, etc.

Uploading Images and Documents

You’re also able to upload any imaging and documentation that’s relevant to the patient’s diagnosis. There are three sections:

  • Laboratory Documents

  • Imaging Information

  • Documents (good for adding in old medical records or any miscellaneous documents)

Each section also has a ‘Notes’ category where the physician should note their interpretation of the images, as well as anything that’s abnormal.

Images can be uploaded via the ‘Browse Files’ button, or you can drag and drop them into the appropriate section. If you’re on a tablet/phone, you’re also able to take photos on your device.

Supported file types include:

  • .mp4 (video)

  • .mov (video)

  • .jpg/jpeg (image)

  • .dcm/.dicom (image)

  • .pdf

  • .docx (text)

  • .txt (text)

  • .xlsx (spreadsheet)

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