Encounters are the clinical record of your interaction with the patient. Our software uses the standard SOAP note as the format for all notes (although you can view the chart in different views).
The acronym SOAP stands for SUBJECTIVE, OBJECTIVE, ASSESSMENT, and PLAN. Documentation of patient complaint(s) and treatment must be consistent, concise, and comprehensive. Many offices use the SOAP note format to standardize medical evaluation entries made in clinical records.
The four parts of a SOAP note are outlined below.
1. SUBJECTIVE - The initial portion of the SOAP note format consists of subjective observations. These are symptoms verbally given to providers by the patient (or by a family member or friend). These subjective observations could include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort, or illness.
2. OBJECTIVE - The next part of the format is the objective observation. These objective observations include symptoms that the provider can actually see, measure, hear, touch, feel, or smell. Included in objective observations are measurements such as visual acuity, refractive findings, vital signs and the results of other tests.
3. ASSESSMENT - Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a corneal ulcer. However, an assessment may not be clear and could include several diagnostic possibilities or description of symptoms. Our software uses standard ICD-9 codes (with the option of using ICD-10 codes).
4. PLAN - The last part of the SOAP note is the plan. The plan may include treatment medications, final refractive prescription, additional tests ordered for the patient, treatments performed (e.g., minor surgical procedure such as foreign body removal), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions/education, and follow-up directions for the patient.