Encounters – Charting a SOAP Note (Clinical Staff)

The heart of the EHR system is the Encounter. In this section we’ll address all of the elements that go into creating an Encounter, and then walking through each element of the Encounter and explaining each in detail and wrap up by addressing the areas that Clinical Staff (providers & non-providers) are most likely to be responsible for completing.

The following course contain instruction and details on how to properly chart a SOAP Note;

Creating an Encounter from the Dashboard Appointment
- I. Accessing existing encounters
- II. Areas clinical staff is responsible for completing

And then move into the Standard Encounter Visit tabs:

Summary
- I. CC
- II. HPI (Occasionally)
- III. Hx
- IV. Meds/Allergies
- V. ROS (Sometimes)
- VI. PE (rarely)
- VII. Vitals
- VIII. POC
- IX. Results
- X. Assessment (sometimes)
- XI. Plan (sometimes)
- XII. Superbill