Creating clinically valid Soap Notes has never been easier than when using ChiroPulse365. One tool offered is the Point & Click Soap Wizard which allows you to create detailed & specific – yet clinically relevant – Soap Notes. This is touchscreen friendly and can allow the creation of a Soap Note without typing. It is even easier than it appears since once the initial Soap is created, the data collected is quickly viewed & used to start your next note for the patient’s next office visit. This allows continuity & validity of your clinical documentation for all your patients.
The first thing to do for your patients is setup the Chief Complaints & Exams for the specific Claim (i.e. patient’s treatment episode). Remember you can have multiple simultaneous Claims running, each with thier own ICD-9 diagnosis, complaints, etc. When you create a new Soap Note you will be asked to select which claim the note is for.
create a new soap note & select the claim it is for
While in the SOAP Note Editor or Wizard you can quickly jump to Claim Wizard Page-3 to view & change the complaints & exams! Do this effortlessly with the top menu or keyboard hotkey CTRL+F3. Note that the same keyboard shortcut is universally used in ChiroPulse365, in many windows such as Office notebook, Travelcard, Patient Homepage, Scheduler, Soap Notes, History, etc.
Use the menubar in Soap Wizard to quickly open Claim Wizard page-3
The first goal is to establish what you want to clinically monitor while the patient is under your care for this treatment period (ie. claim). Complaint & Exam packages can be created for frequently used diagnostic scenarios. This will allow you to rapidly enter a preset package for “sciatica” or “headaches” with complaints & exams in your specified order. These can be changed on-the-fly while doing Soaps using add/insert, omit & remove; or changed permanently (all soaps going forward) via Claim Wizard. Just remember it is best to setup your starting point in the Claim Wizard first.
In the example below we will change the primary complaint (selected in blue) in Claim Wizard. We then save the changes so that the appropriate complaints will appear when we create a new Soap Note for this Patient & claim.
Claim Wizard page-3 Complaints & Exams
The Point/Click Wizard has started in the picture below, ready to create a new Soap Note. In the Wizard you work from top to bottom, left to right & remember that almost everything is “clickable” or selectable. You can see in this example three (3) Chief Complaints are used for Carmella but the “shoulder-arm…” complaint is Omitted for this note meaning we will skip that complaint for today’s note. Use omit to skip a complaint or exam while keeping it in the Claim Wizard for use later, such as if an exacerbation occurs. You can delete the complaint so it will not appear in the next new Soap note.
Use the SOAP tabs to navigate between components or simply use Next/F3 to go from finding to finding (ie. location… description… better… aggravated) to quickly loop through & visually create your Soap Note. The keyboard shortcuts allow you to navigate a Soap without grabbing for the mouse. If you are using the mouse however, you can click on any blue text link to jump to that data panel.
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Team Pulse Tips & Hints clinical, notes, soap, touchscreen
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