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soap-notes

Streamline your SOAP notes with patient management software!

The recording of patient information has been traced back to cave paintings and stone carvings of prehistoric times and Egyptian surgical case reports documented on papyrus.

It was Dr. Lawrence Weed, professor of medicine and pharmacology at Yale University who was inspired to create the basis of the SOAP note in the 1950’s to improve documentation and clinical reasoning in medicine.[1]

As part of a more patient-centric approach to documentation Weed recommended that the progress note be organised into four sections:

Subjective

Objective

Assessment

Plan

Today it is not just doctors who interact with SOAP notes but also physiotherapists, occupational therapists, chiropractors, patients, billing and legal professionals, administrators and other health practitioners. SOAP notes are now the most common method of documentation used by providers to input notes into patients’ medical records.

In the past several years, electronic health records have also become the norm rather than the exception for healthcare providers. They are used in numerous health care settings to support a holistic approach to complex and wide ranging treatments for patients.

SOAP notes should be accurate, easy to follow, access and share

One of the most critical skills that allied health professionals must learn is effective documentation. Your documentation guides diagnosis, treatment, referral to other services and is a reflection of you and your profession.

Professional note taking and documentation is a skill and like any skill, it can be learned and improved.

Cliniknote is designed by medical professionals to streamline and improve SOAP note taking

The combined use of electronic health records and clinical note taking software has the potential to improve the overall quality of client care, increase efficiency of health practitioners, and reduce health care costs.

The advantage of Cliniknote software is that it allows you to organise patient information, diagnosis notes, administration tasks and follow-ups in easy to find places.

Cliniknote reminds clinicians of specific tasks while providing a framework for evaluating and accessing relevant information simply. The more customised and efficiently thorough a SOAP note is, the easier it is for clinicians to follow.

When Allied health professionals collaborate with clients and other medical services during evaluation and intervention to ensure that patients have an active role in their care, that collaboration is easily documented through Cliniknote software.

Having access to clear information at every step of the patient experience improves the quality of treatment provided by allied health professionals and the patient’s recovery.

If you are interested in taking your SOAP notes digital and streamlining your patient management system, let us take you through an in-depth exploration of how you can do it with a 30 day Cliniknote software trial.

[1] Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M. The hidden curricula of medical education: A scoping review. Acad Med. 2018;93:648–656.

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