The patient SOAP is the core of how Shepherd works because it's the core of how you work. Instead of 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 based on treatments and services you are performing.

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.

The SOAP Summary is where you’ll land whenever you open a patient’s SOAP. The SOAP summary includes the following:

Under the actions menu, you can export and email the SOAP and print a cage card for that visit. You can also edit the check in time or delete the SOAP based on user role permissions.

The subjective is where patient history is collected, including the initial complaint and any current medications.

Note: previously prescribed medications will populate for quick reference, but they will need to be documented in the current medication section in order to populate in that SOAP.

The objective is where vitals and physical exam details are documented. You can add multiple vitals and exams within one SOAP. For vital entries, you will see a comparison table at the bottom of the SOAP for quick reference.

There are two ways to add an exam:

Remember, Shepherd is designed for efficiency and to save you time to be sure you are using default values in your exam templates or loading a past exam. Note: you can also use shortcuts within the SOAP for quick entries!

Body maps are available within the exams and allow you to easily draw or notate things like lumps and bumps. Just like the exams, you can select to load a previous body map to add the new lump without having to draw all of the existing lumps again!

The assessment is where problems, diagnoses, chronic conditions, and prognosis are noted along with the overall assessment notes, including rule-outs.

Tip: if you have discharge instructions linked to a diagnosis, they will automatically populate in the SOAP when a diagnosis is added.

If you are using an integrated diagnostic partner, such as Zoetis Reference Labs, you will see a Diagnostics section under the assessment. This is where you can see pending and completed orders as well as view the results in the partner's online portal. If you have a lab integration enabled, the PDF will also automatically be uploaded into the Laboratory section.

The Laboratory section is where you can upload lab results and leave notes regarding the findings. The notes are helpful for quick reference in the future so you do not have to open all of the lab files.

The Imaging section is where you can upload any diagnostic images or images taken of the patient, such as a swollen eye, and leave notes regarding the images.

The Documents section is where you can upload previous medical history relevant to that SOAP and or any external/paper forms completed for that visit.

The Forms section is where you can upload consent forms completed by the client, either on paper or electronically through Shepherd. This is also where you will create internal forms such as anesthesia forms and dental charts.

The recommendation is your professional recommendation as to how to best care for the patient. Also, additional notes can be left to document client communication outside of the exam.

This is where you will order treatments and services to be performed during the visit. Tx's can be marked as administered directly from this section or you can schedule the Tx's if they will be done at a later time.

If you have an approved estimate on the SOAP summary, that estimate can be pushed to the Tx plan here to avoid having to re-enter all of the items.

For injections, Shepherd will calculate a quantity to be given based on a mg/kg dose entered. In the example below, we know that Cerenia is 1 mg/kg, and with this patient's weight, it is letting us know to administer 2.268 mLs. Note: it requires a new weight to be entered within the current SOAP to avoid calculating doses off previous weight entries.

When ordering Tx's, you can relay additional notes to the team under Additional Instructions. This may be used for what x-ray views you want to be taken, if an injection needs to be given slowly over a period of time, etc.

If you are scheduling a Tx, you can set a treatment priority for STAT, scheduled, or PRN. When scheduling a Tx, you can note how many times and how often that Tx will be given.

Once a treatment is administered, it will be logged under the Tx history to avoid having to type it separately in the medical record. Under Admin, each product can be set up with default medical record notes, again, saving you time from having to manually type a lot of details. In the example below, "Given SC in right hind limb." is set up as a default note in Admin for the Rabies item so once it was administered, this populated automatically and now all you have to do is make any corrections or additions and add the note.

Prescriptions can be added within a SOAP or outside of a SOAP on the patient's profile directly if it is being filled outside of a visit. You can add an in-house Rx or a written Rx. Check out our prescription guide to learn more about creating an Rx.

Note: just like the Tx's as soon as you create an in-house prescription, it will automatically add it to the invoice.

The SOAP charges page shows you what items are being added to the invoice for this particular patient. Note: you may have an invoice with more than one patient on it.

If you need to change the invoice to which these SOAP charges are being added, select the drop-down under Change Invoice and either select a different invoice or a new invoice.