SOAP Note and eMedley Entries

As a medical professional, you’re likely familiar with the term SOAP note. This standardized documentation method is used in healthcare to record patient progress and communicate with other providers. In this blog post, we’ll take a closer look at SOAP notes and eMedley entries. We’ll discuss how they’re different, when to use each one, and offer some tips on how to make the most of each method.

SOAP Note

A SOAP note is a progress note that contains specific information about a patient, including a subjective assessment of the patient’s condition, objective data about the patient’s condition, assessment of the patient’s progress, and a plan for future care.

eMedley is an electronic medical record (EMR) system that allows healthcare providers to document patient encounters in a structured format. eMedley entries are based on the SOAP note format and contain similar information as a SOAP note.

EMedley Entries

eMedley entries are a great way to keep track of your medical history and progress. They can be used to record appointments, medications, procedures, and more.

When you create an eMedley entry, you’ll be asked for some basic information about the appointment or procedure. This includes the date, time, location, provider, and type of service. You can also include notes about the visit.

Once you’ve created an entry, you can add additional details like symptoms, test results, andtreatment plan. You can also add attachments like images or documents.

eMedley entries are a valuable tool for both patients and providers. They help you keep track of your medical history and progress so you can make informed decisions about your health care.

How to Write a SOAP Note

A SOAP note is a progress note that contains specific information about a patient, including a subjective assessment of the patient’s condition, objective data about the patient’s health, analysis and interpretation of the data, and recommendations for treatment.

While there is no one way to format a SOAP note, most contain four sections:

Subjective: This section includes information about the patient that has been gathered from speaking with the patient and/or their family. This may include information about the chief complaint, current symptoms, past medical history, etc.

Objective: This section includes information that has been gathered through physical examination and/or testing. This may include vital signs, results of lab tests, etc.

Assessment: In this section, the clinician interprets the data collected in the subjective and objective sections to reach a diagnosis or make a decision about treatment.

Plan: The final section includes recommendations for treatment or follow-up care.

How to Write an eMedley Entry

An eMedley entry is a type of SOAP note that is used to document patient care in an electronic medical record (EMR). The eMedley format includes four main sections: Subjective, Objective, Assessment, and Plan.

Subjective: The subjective section is where the clinician documents the patient’s history and chief complaint. This information is typically gathered from the patient interview.

Objective: The objective section is where the clinician documents the results of the physical examination and any diagnostic tests that were performed.

Assessment: The assessment section is where the clinician documents their clinical impression of the patient’s condition. This may include a diagnosis, differential diagnosis, or working diagnosis.

Plan: The plan section is where the clinician documents the treatment plan for the patient. This may include medications, referrals to other providers, or follow-up appointments.

Tips for Writing SOAP Notes and eMedley Entries

When writing SOAP notes and eMedley entries, there are a few things to keep in mind. Here are some tips to help you write clear and concise notes:

1. Use abbreviations sparingly. While abbreviations can save time when writing, too many can make your notes difficult to read. Only use abbreviations that will be easily understood by those reading your notes.

2. Write in complete sentences. This will help ensure that your thoughts are conveyed clearly and concisely.

3. Be specific. When documenting symptoms or treatments, be as specific as possible. This will help the person reading your notes understand exactly what was done and what was observed.

4. Use active voice. Active voice makes your writing more concise and easier to read. For example, “The patient was seen” can be rewritten as “I saw the patient.”

5. Avoid using personal pronouns. While it may be tempting to use pronouns such as “I” or “we,” this can make your notes sound biased or unprofessional

Conclusion

Completing SOAP notes and eMedley entries can be time-consuming, but the process is an important part of providing quality patient care. By taking the time to document each patient encounter thoroughly, you can ensure that you are providing the best possible care. In addition, by using a standardized format for documentation, you can improve communication with other members of the healthcare team.