The sections of this guide are:
Clinical Visit Documentation
All of the tools at www.soapnote.org are capable of generating plain text that can be inserted into any electronic health record (EHR).
There are many, many pages of partial and complete visit templates. The most frequently visited page at the site is at this page
Once the desired output is produced, it can be copied or saved for future use. This information is not tracked by the SOAPnote Project.
Clinical Decision Making
Another important use of the tools at www.soapnote.org is assistance with clinical decision making. Physicians use decision tools every day in practice. Documentation of use of clinical decision tools helps support diagnostic and treatment plans.
There are hundreds of clinical decision tools at the site.
An important tool that is often used is the Pulmonary Embolism Rule Out Criteria Score at this page
After input of clinical factors, an interpretation is provided in the output.
This output may be inserted into a note and can also be saved for future use or research. This information is not tracked by the SOAPnote Project.
Clinical Chart Review
Another use of the tools at www.soapnote.org is chart review. This is a process that can consume a lot of time and paper and is often frustrating to physicians.
To streamline the process, physicians can develop chart review forms for their office.
They may copy the forms available at www.soapnote.org/tag/chart-review/, share their form with their staff, and then have their staff send the reviews back to them electronically. This eliminates at least some of the paper process.
Once the reviews are performed and submitted, they can be downloaded as a “comma-separated value” (CSV) file and imported into a spreadsheet program for tracking and analysis. As with other data, this information is not tracked by the SOAPnote Project.
Here is the form for reviewing charts:
The output can be viewed and can be downloaded as a CSV file. A CSV file can be opened in a spreadsheet.