SOAP Notes and Clinical Documentation

SOAP Format

DigitalPatientChart uses the standard SOAP format for clinical documentation:

• S — Subjective: Patient's reported symptoms, complaints, and history.
• O — Objective: Your clinical findings, exam results, vitals, and observations.
• A — Assessment: Diagnosis, clinical impression, and ICD-10 coding.
• P — Plan: Treatment plan, prescriptions, referrals, and follow-up instructions.

Using Templates

Create templates for common visit types to speed up documentation. Templates pre-populate fields while still allowing customization for each patient encounter.

Creating a Note

1. Open the patient's appointment from the calendar or patient record.
2. Click New SOAP Note.
3. Select a template or start from blank.
4. Complete each section. Use the body diagram tool for marking areas of concern.
5. Add ICD-10 codes — the system provides search-as-you-type with common codes.
6. Sign and finalize the note.

Editing After Signing

Signed notes cannot be altered, but you can add an addendum at any time. The original note and all addenda are retained in the audit trail.