SOAP Overview
Welcome to Shepherd’s SOAP Overview
The patient SOAP is the core of how Shepherd works because it's the core of how you work. Instead of you having to create an invoice as you're caring for a patient (all while recording how you care for them), Shepherd lets you care for a patient and automatically generates discharge instructions, invoices, and tasks.
Let’s take a look at the SOAP workflow to see how it streamlines your job while also saving you time and helping you account for all charges intuitively and accurately.
How to get to a Patient’s SOAP
The first screen you’ll come to after you’ve logged into Shepherd is the Dashboard. From the Dashboard, click just to the right of the patient’s name.
Note: clicking the patient’s picture or name will take you to that patient’s dashboard. Clicking the client name will take you to the client dashboard. If you don’t see SOAP at the top of the next screen, you can go back and try again.
This is Shepherd's Dashboard
Every patient's SOAP is broken down into the standard SOAP sections, as well as a few extras. Those sections are:
SOAP Summary
The SOAP Summary is where you’ll land whenever you open a patient’s SOAP.
Here's where you can start gathering and recording information about your patient. Here’s a quick breakdown of the fields and what you can do:
SOAP Title: an overview for the patient's medical history
Select a prescribing doctor (useful for production)
Add the patient's current location
Add a patient's weight
You can also create an estimate (which is more accurate when a patient's weight is input).
Tip: this can also be done outside of a SOAP in the patient's dashboard.
The SOAP Summary
Subjective
To navigate to the ‘Subjective’ section, click the ‘S’.
The ‘Subjective’ section of the patient’s SOAP is likely very familiar to you, even if you’re unfamiliar with seeing patients in a SOAP format. Here’s what you can document when you’re in the ‘Subjective’ section:
Initial complaint
Current medications/supplements
History
Tip: we made this section so you can start filling it out as you're checking in the patient.
The Subjective tab
Objective
To navigate to the ‘Objective’ section, click the ‘O.’
The 'Objective' section of a patient's SOAP is where we start gathering specific details about a patient's medical history. In this section, you’re able to:
Input the patient's vitals
Add a physical exam
Compare vitals
The Objective tab
Assessment
To navigate to the ‘Assessment’ section, click the ‘A.’
The 'Assessment' section of the SOAP is where the doctor can start taking notes and adding different pieces to the patient's medical record. They’ll be able to record:
The problem list
Diagnosis
Chronic ailments
Patient assessment
Prognosis
Doctors can also add documents into the medical record in the ‘Assessment’ section.
Documents are broken into
Imaging
Lab
Documents (general)
Plan
To navigate to the ‘Plan’ section, click the ‘P.’
The ‘Plan’ section of the patient SOAP is one of the most critical to understand if you’re going to get the most out of Shepherd. It’s broken into 3 sections:
Treatment Plan (Tx Plan)
Treatment Schedule (Tx Schedule)
Treatment History (Tx History)
The Plan tab
Discharge Instructions
To navigate to the ‘Discharge Instructions’ section, click the ‘D.’
Depending on the treatments, products, prescriptions, and the patient's diagnosis, your discharge instructions will automatically be created.
Shepherd is available with hundreds of approved instructions, and you can also add your own for individual products and treatments for anything you like to give explicit client instruction for. Do that by clicking the ‘Add New’ button.
The Discharge Instructions tab
Prescriptions
To navigate to the ‘Prescriptions’ section, click the ‘Rx.’
Similarly to products and treatments administered in the ‘Treatment’ section, all prescriptions added in this section will automatically:
Populate in the invoice
Generate discharge instructions (if applicable)
Note: prescriptions (and prescription refills) can be set up to track production.
The Prescriptions tab (after 'Add New' was clicked)
SOAP Charges
To navigate to the ‘SOAP Charges’ section, click the icon on the far right.
All treatments, products, and services administered through the SOAP will have populated on the SOAP Charges page.
However, if you need to add something to your patient’s invoice that doesn’t need to appear in the medical record (dental chews, non-prescription food, etc.) those can be added in ‘Add Invoice Items.’
Once everything is added on the SOAP Charges page, click ‘View Invoice’ to open the invoice and collect your payment.
The SOAP Charges tab