SOAP Note and eMedley Entries

Health care documentation is a necessary part of providing quality patient care. In this blog post, we will explore two types of health care documentation: SOAP notes and eMedley entries. We will discuss the purposes of each type of documentation and when they should be used. This post is geared towards health care providers, but patients may also find it helpful to understand the types of documentation their providers use.

The Purpose of SOAP Notes

The purpose of SOAP notes is to document the progress of a patient’s care. They are usually written by doctors, nurses, or other health care professionals. The acronym “SOAP” stands for Subjective, Objective, Assessment, and Plan.

Subjective: The subjective portion of a SOAP note includes information about the patient’s symptoms that the health care professional gathered from talking to the patient.

Objective: The objective portion of a SOAP note includes information about the patient that the health care professional gathered from observing the patient or from medical tests.

Assessment: The assessment portion of a SOAP note includes the health care professional’s interpretation of the information in the subjective and objective portions. The assessment is usually a diagnosis or a list of possible diagnoses.

Plan: The plan portion of a SOAP note includes the health care professional’s recommendations for treating the patient’s condition.

What is eMedley?

eMedley is a secure, online platform that enables healthcare providers to share patient information and coordinate care. eMedley provides a single, central location for patient information, making it easy for providers to access and update medical records. eMedley also offers secure messaging and video conferencing capabilities, making it an ideal platform for telemedicine visits.

How to Use SOAP Notes and eMedley

There are a few different ways to use SOAP notes and eMedley entries. You can use them for individual patients or for groups of patients.

For individual patients, you will want to input their information into the system. This includes their name, date of birth, address, and phone number. You will also need to create a username and password for them. Once this is done, you can begin inputting SOAP notes for each patient visit.

For groups of patients, you can create a shared document that all members of the group can access. This is useful for sharing treatment plans, scheduling appointments, and communicating with other members of the team. To do this, simply create a new document in eMedley and invite all members of the group to view it.

Benefits of SOAP Notes and eMedley

There are many benefits to using SOAP notes and eMedley entries when documenting patient care. SOAP notes provide a concise and standardized way to document patient care, which can be easily understood by other healthcare providers. eMedley entries allow for more detailed documentation of patient care, and can be customized to meet the needs of the individual provider. Both SOAP notes and eMedley entries are electronic medical records (EMRs), which provide a way to store and share patient information electronically. EMRs can improve communication between healthcare providers, and reduce the risk of medical errors.

Drawbacks of SOAP Notes and eMedley

There are a few drawbacks to using SOAP notes and eMedley entries. First, they can be time-consuming to write, especially if you are including a lot of detail. Second, they can be difficult to read if they are not well-organized. Finally, if you are not careful, you may inadvertently leave out important information.

How to Make the Most Out of SOAP Notes and eMedley

If you are looking to get the most out of your SOAP notes and eMedley entries, here are a few tips:

1. Make sure to include all relevant information in your SOAP notes. This includes the patient’s chief complaint, history of present illness, past medical history, medications, family history, social history, review of systems, and physical exam.

2. Be as concise as possible in your eMedley entries. The goal is to provide enough information to remind you of the patient encounter but not so much that it becomes cumbersome to read through.

3. Use abbreviations and acronyms sparingly in both your SOAP notes and eMedley entries. While they can save time when used correctly, they can also lead to confusion if not used properly. If you are unsure about an abbreviation or acronym, spell it out in full the first time it is used.

4. Keep your SOAP notes and eMedley entries well organized. This will help you quickly find the information you need when reviewing a patient’s chart later on.

5. Make sure your handwriting is legible! This may seem like a no-brainer but it is important nonetheless. If your writing is illegible, it can cause delays in care if someone else needs to interpret what you have written down.

Conclusion

The SOAP note and eMedley entry are both important parts of the medical process. The SOAP note is used to document a patient’s symptoms, while the eMedley entry is used to document a patient’s electronic medical record. Both of these tools are essential for providing quality care to patients.