What Does SOAP Stand For?
Subjective
Record subjective information from the patient themselves. It starts with what their chief complaint is. What’s hurting them? Where does it hurt? Describe the pain and severity. What kind of other symptoms are you experiencing?
Objective
Record objective data with tools and your own observations. These can include blood pressure, weight, and the results of any other tests. In the chiropractic field, this can also include the results of neurological tests, imaging tests, and examination of the pain area.
Assessment
Now comes the time to analyze the information you’ve gathered and make a diagnosis as well as decide what the best treatment would be.
Plan
With a sound assessment of the patient’s chief complaint, you can commence with treatment. This involves any immediate actions you can do during their visit, as well as creating a strategy for the patient going forward. This can include suggested lifestyle changes or medication if necessary. In the chiropractic field, this would include immediate adjustments, a timeline of recommended visits, suggestions on diet and exercise, and if necessary, lab work.
What Makes a Good SOAP Note?
Copious note taking is never a bad thing. If you’re a medical professional, then you rely on your notes to serve the best quality care to your patients. SOAP notes are especially essential for taking care of regular patients. You can’t always rely on your memory— you need detailed notes and charts about your patients so when they come in you already know everything about them, the details of their pain, and what you discussed during their last visit.
Having your SOAP notes accessible at a moment’s notice will allow you to better serve patients as they visit. After meeting with a patient, you need to organize your notes, but it can take time. More time on filing your paperwork means less time with other patients and maintaining your practice.
How Does eFileCabinet Make Your SOAP Notes More Dynamic?
Whether you make your SOAP notes digitally or physically, eFileCabinet can help you efficiently organize them faster and easier.
eFileCabinet uses optical character recognition (OCR) technology to make both filing and retrieving any document automated and effortless. Using a template for your most used forms, like a standard SOAP document, the software can recognize the text in selected fields, creating a profile of metadata. The document management system can then use that data to automate where that form should be filed, even creating a new folder if one doesn’t exist. For example, if you file an intake or SOAP document for a new patient, the system can recognize that there isn’t a folder for that patient yet and will create a new one with their name.
When you need to look for a SOAP note, searching for a document is just as easy as it was filing it. eFileCabinet uses OCR for its full-text search, meaning you don’t have to know the exact name of the file, just any of the text you know is in it. If you’re looking for the SOAP note on a certain patient, you can just type in their name, and the system will retrieve all documents and folders with that name in it.
eFileCabinet makes it easier to organize SOAP notes. These documents are essential for providing quality care to your patients, but you shouldn’t have to spend double the time on paperwork that you did with your patient. Automate your filing, so you can spend less time on documents and more time with your patients. To see how eFileCabinet can automate your filing, click here to view a free, personalized demo.
