Creating a S.O.A.P. Note
To create a pre-formatted S.O.A.P. note very quickly, choose the S.O.A.P. note format. Follow the following steps to create a S.O.A.P. note.
1. Creating a S.O.A.P. note
Navigate to a client record and click on the "Notes" tab. Locate the " Select a note type" dropdown menu. If you are part of a group practice and do not see this option, you may not have been given permission to create notes for this client. You will need the primary clinician to grant you access.
2. Selecting the note type
Select " S.O.A.P. Note" as the note type and click the Create button.
3. Complete the risk assessment
Use the preformatted area provided to document your client risk assessment.
4. Complete the mental status
Use this preformatted area provided to document your client's mental status. Click "All Within Normal Limits" to set all dropdowns to normal. You may override any individual status options.
5. Complete the S.O.A.P. note sections
Use the text area provided to document your client note. Completing this section is required to save your note.
6. Add primary and additional diagnostic codes
If you plan to print a Superbill or bill the client's insurance carrier for the session, use the dropdown lists provided to search and select the appropriate diagnostic code(s) for your client. You may select a single primary diagnosis code and multiple 'additional' diagnosis codes.
Good To Know
Diagnosis codes saved in the client's treatment plan will automatically copy into any new treatment plan or therapy note.
7. Make a future recommendation
Use this preformatted area provided to document your clinical recommendation moving forward.
8. Linking an appointment to your note
You have the option to link the associated appointment to your note. Use the dropdown list of recent appointments to select the corresponding appointment for this note. Linking an appointment to a note also allows TherapyZen to alert you if you need to sign your note for this session.
- Appointment linking is required if you plan to create a Superbill for the session related to your note.
- Linking an appointment to the note is not required to digitally sign the note for accuracy.
9. Digitally signing your note
Sign the note by clicking the checkbox declaring the document accurate and complete if no further edits will be required. Click " Save" to save the note. Unsigned notes will be saved as a draft and can still be edited. Signed notes can not be edited.