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Physician SOAP Note Charting

ChARM EHR provides physicians with a comprehensive SOAP notes (also called chart notes) section, as part of the encounter workflow. Configurable Physician SOAP templates allows them to quickly document patient visits and let them focus more on the patient than working with the software. When the SOAP note is created, physicians can view the pre-appointment questionnaires filled by the patients, along with the details of patients' previous visits.

SOAP notes allows physicians to quickly enter the patient health information in a standard format, viz.,

Subjective Charting:

This section allows physicians to enter the observation made about the patient, from the patient/caregiver point of view. This is done by talking to the patient to understand their chief complaints, history of present illness, etc.

Objective Charting:

This section allows the observations to be noted down, by visually looking into the patient and by seeing their health vital measurements. Option to perform marking on the medical images, allows physicians to mark the problematic areas in the patient's X-ray and scan images.

Assessment Charting:

In this section, physicians can write assessment notes about the patient's present illness. Diagnoses can be classified through the use of ICD codes.

Plan:

Physicians can enter the plan for treating the diagnosed illness, which includes treatment, medications, therapies, referrals, follow-up care, etc.

ChARM EHR provides various options to create the SOAP note, according to the needs of the physicians and specialists. Physician SOAP templates allows frequently used sections to be customized and saved as templates, so that SOAP notes can be filled in by selecting the template.

Quick Chart Notes:

Quick chart note can be used during phone consultation and in scenario where minimal charting is enough. It includes

  • Consultation Notes
  • New Rx, Lab & Imaging
  • Patient Instruction and Follow up

Brief Chart Notes:

Brief Chart note captures all the sections of SOAP (including vitals and Dx codes) in a single page. It includes

  • Chief Complaints / Symptoms
  • Vitals and Physical Exam
  • Assessment & Dx Codes
  • New Rx, Lab & Imaging
  • Patient Instruction and Follow up

Comprehensive Chart Notes:

As the name indicates, comprehensive encounters can be used in cases, where you need to maintain detailed documentation about the patient visit. These are typically used by specialists treating chronic illnesses.