Write and finalize a SOAP note
SOAP notes keep the clinical reasoning for the visit organized and durable.
1. Start the note
Open SOAP from the encounter. Use a clinic template when one fits, then document each section for the work actually performed.
2. Review linked work
Confirm that problems, prescriptions, vaccines, labs, procedures, and performed work were recorded in their structured workflows as well as described in the note.
3. Finalize the note
Resolve any missing documentation, then finalize. If a finalized note must be corrected, use the amendment or replacement workflow so the original evidence remains available.