The SOAP is the core of how Shepherd works - because it's the core of how you work. Instead of having to manage invoices and discharge instructions separately while treating a patient, Shepherd does the heavy lifting for you. As you care for the patient, treatments and services are recorded in real time and automatically populate invoices, discharge instructions, tasks, and reminders.
Let’s walk through how the SOAP workflow in Shepherd saves time and ensures nothing is missed.
Take a Look
SOAP Summary
When you open a SOAP, you’ll land on the SOAP Summary. This section provides an overview of key visit information:
Status: Indicates where the SOAP appears on the dashboard
Active
In Review
Lab Pending
Locked
Locking a SOAP prevents edits (only users with permission can unlock)
SOAP Title: A brief descriptor for easy reference in the patient’s history
Location: Used to show where the patient is within the clinic
Patient Weight: Can be entered here or through vitals in the Objective section
Supervising Doctor: Used for reporting, production tracking, and dashboard filtering
Assigned Users: Typically used for technicians and visible on the dashboard and whiteboard
Estimates: Create a new estimate or import an existing one (learn more here)
Addendum Information: Add files or notes after the SOAP is locked
SOAP Actions
From here, you can export, email, or print the SOAP. You can also print a cage card, edit check-in time, or delete the SOAP (based on user permissions).
Subjective
The Subjective section is where patient history is documented, including Initial Complaint, Current Medications & Supplements, and Patient Medication History.
Patient Medication History
This collapsible section provides fast and organized access to a patient's medication history from the last year.
12-Month Prescription Snapshot: instantly view a patient’s prescription history over the past year
Interactive Table View: sort prescriptions by name, view Rx numbers at a glance, and click into any record for more detail
Written vs. In-House Visibility: easily distinguish between written prescriptions and those filled in-house
Prescriber & Timestamp Insights: know exactly who prescribed the medication and when, with clear timestamps.
Latest SOAP Medication Notes: a dedicated section displays notes from the most recent SOAP that included medications, offering helpful context alongside prescription data
Objective
The Objective is where vitals and physical exam findings are recorded. You can enter multiple sets of vitals or exams in a single SOAP. For vital entries, you will see a comparison table at the bottom of the SOAP for quick reference.
Physical Exams
There are two ways to add an exam. You can:
Add a new exam from your pre-loaded or custom templates
Load a past exam to reuse findings
To save time, use default values in your exam templates or load a past exam. You can also use shortcuts within the SOAP for quick entries.
Body Maps
Add a Body Map to notate physical findings (e.g., lumps or wounds). You can also load a previous map to build on prior annotations.
Assessment
Use the Assessment section to document:
Problems
Diagnoses
Chronic conditions
Prognosis
Rule-outs and assessment notes
If you’ve linked discharge instructions to a diagnosis in Admin, they’ll auto-populate when that diagnosis is selected.
Diagnostics (Lab Integrations)
If using an integrated partner like IDEXX Reference Labs or Zoetis Reference Labs, the Diagnostics section appears here. You can:
View pending and completed orders
Access results in the partner’s portal
View PDFs auto-uploaded to the Laboratory section
Laboratory
Upload lab results and include notes for future reference - helpful when reviewing patient history without opening each attachment.
Imaging
Upload diagnostic or reference images (e.g., radiographs or photos of injuries) and document observations in the Imaging section. If using an integrated partner like IDEXX Web PACS, imaging results will populate here.
Documents
Upload outside medical records, client-provided documents, or any paper forms completed during the visit.
Forms
Use this section for both client-signed consent forms and internal documents like anesthesia sheets and dental charts. Forms can be completed electronically or uploaded from paper.
Plan
The Plan section is where you document your recommendations and treatments for the patient during their visit. It includes your professional guidance, treatments to be administered, and tools for scheduling, tracking, and communicating care.
Tx Plan
Use the Tx Plan to document your medical recommendations and outline how the patient will be treated. You can also include any relevant client communication that occurred outside of the physical exam.
Order Treatments
This is where you’ll order treatments and services to be performed. From here, treatments can be:
Marked as Administered
Scheduled for later in the visit
If an approved estimate is already linked to the SOAP, you can push items from that estimate directly into the Tx Plan without re-entering them.
Treatments are the foundation of many automation within Shepherd. When you mark a treatment as administered, it will:
Automatically log in the medical record
Be added to the invoice
Trigger any linked discharge instructions
Generate linked client reminder notifications
Generate linked internal tasks (e.g., call backs)
Because the invoice and medical record are connected, treatments should only be administered once completed. To remove an item from the invoice, the treatment must be undone.
Weight-Based Dosing for Injections
When entering a weight-based dose (e.g., mg/kg), Shepherd will automatically calculate the correct volume based on the patient’s weight in the current SOAP.
A current SOAP weight is required for accurate dosing to avoid calculating doses from previous weight entries.
Additional Instructions
When ordering a treatment, you can include extra notes for your team under Additional Instructions. For example, you might specify:
Required x-ray views
Instructions for slow injection
Any special handling requirements
Client Medication Toggle
If the client brings their own medication and it will be administered in-clinic, use the Client Medication toggle. This ensures the item is logged but not added to the invoice.
Tx Schedule
Scheduled treatments can be prioritized using:
STAT
Scheduled
PRN
You can specify how many times and how often a treatment should be administered.
Tx History
Once treatments are administered, they are logged in the Tx History section. This eliminates the need to manually write medical record entries.
In Admin, each treatment item can be configured with a default medical note. For example, if “Given SC in right hind limb” is the default note for Rabies, that text will appear automatically when the item is administered. You can adjust or add to the note as needed before saving.
Setting up product defaults in Admin saves time and ensures consistency across your records.
Rx (Prescriptions)
Prescriptions can be entered in the SOAP or directly from the patient’s profile.
Add In-House or Written prescriptions
In-house prescriptions will automatically be added to the invoice
Learn more about prescriptions in our Prescription Guide.
SOAP Charges
The SOAP Charges page displays all items that have been added to the invoice as part of the current SOAP.
Invoices can include items from more than one patient, depending on how the visit is structured
If you need to assign the SOAP charges to a different invoice:
Click the dropdown under Change Invoice
Select an existing invoice or create a new one
