SOAP: Assessment

To navigate to the ‘Assessment’ section:

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

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:

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.’

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.

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

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.

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.

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

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: