We'll be going through the sections of the Scribenote SOAP note form one-by-one.
- (1) Patient's name. If this is a quicknote, it'll just say "Quicknote."
- (2) Use Template button. Click this to select a template to apply to your note.
- (3) Audio player. Notes that do not have recordings linked will not have this.
- (4) Date the note was recorded. You can edit this date by clicking edit note.
- (5) Word autocomplete toggle. Toggle this on to get word suggestions as you type.
You will only see this field if you are creating a Quicknote. Here, you can put in any information regarding the patient whom the note is for.
Enter any Subjective data about the appointment here, such as observed symptoms, recent history and information about the patient, or any additional relevant information from the owner.
- (1) Edit Fields toggle.
- (2) Use Blank toggle.
- (3) Custom fields section.
The Objective section has default fields separated into Vitals, Systems, and Overall.
If you do not need some of these fields in your note, you can toggle the Edit Fields toggle and then delete the fields you do not want by clicking the icon.
If you want to restore the fields to the defaults, click the Restore Default Fields button.
You can add new custom fields by clicking the Add New Field at the bottom of the section.
Once you have added a field, you must give it a name (1). You can optionally set the symmetry of this field by selecting a symmetry type from the dropdown (3). Note that this will split the default field into two, for two separate values corresponding to each symmetrical side.
If you do not want any fields in the Objective section at all, you can toggle the Use Blank switch and the section will become a generic text box like in the Subjective, Assessment, and Plan sections.
Enter any Assessment data about the appointment here, such as an analysis of symptoms, proposed diagnosis, or reasoning.
Enter any Plan data about the appointment here, such as medications, surgeries, additional testing, or recommendations to the owner.
When you enter additional information into these sections, it will be added to the Patient's notebook as shown below.
For more information about key patient information, click here.
You may attach various file types to your notes, such as PDFs, images, videos, and other documents. To do so, drag and drop files into the attachments box, or click to open your computer's file browser.
If you attach any files to the note, they will be automatically uploaded and submitted when you save the note or submit it. Note that these files will stay associated with the note they are uploaded to, as well as with that patient's profile (if the note is a patient note).
You may choose to email a note directly from the note form. You can choose between sending the note as a webpage link, or including it directly within the email (embedded text). If you'd like to include attachments in the email, toggle the Include attachments option. This is only an option if you select the "Export as link" option.
The note will be sent to the addresses you enter here, as well as to the Auto Export email address (if applicable).
- (1) Delete button. This will delete the note.
- (2) Cancel button. This will cancel editing the note and remove any edits you have made.
- (3) Save as Draft button. This will save the current note as a draft. It can then be re-opened from the Dashboard
- (4) Save Note button. This will complete the current note and save it to the Patient Notebook, or the Quicknotes page, depending on if it is for a patient or not.