Documenting SOAP Information

NextGen® Adaptive Content Engine Help Enterprise 8

SOAP Template

You can review and modify the documented patient intake and histories information on the SOAP template. You can review the Asthma Flowsheet, Allergy Test Flowsheet, Spirometry, and Nebulizer panels. You also can document physical exam, assessment plan, and communication details. SOAP Link Icons The icons for various links appear on the SOAP template. Document the Patient's Reason for Visit as a Provider The reason for visit added by the intake staff on the Intake template appears on the SOAP template. Patient's History Summary Documentation by Provider You can document a patient's past medical or surgical history, interim, social, family, and diagnostic study history in the History Summary panel. Document Vital Signs The provider reviews the vital signs added by the Intake staff on the Intake template and makes the applicable changes. Patient's Physical Exam You can examine a patient and document the associated information using the Physical Exam panel that displays a list of exam cate

NextGen® Adaptive Content Engine Help Enterprise 8

SOAP Template

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, history, and plan information. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan Although the you could enter the reason for visit and HPI on the Intake template, there are options available on the SOAP tab that are not available on the Intake tab. Parent topic: The Provider Workflow

NextGen® Adaptive Content Engine Help Enterprise 8

The SOAP Template

You can use SOAP to review the patient information gathered during intake and to document the exam, assessment, and plan. On the SOAP template, you can review the patient's visit type, messages, and risk indicators. You can indicate if the patient is new or established for the current encounter on the header of the SOAP template. You can also review or document the following: General information Reason for visit History summary Review of systems Vital signs Physical exam Assessment and plan Parent topic: Review of SOAP Details by Provider Parent topic: Overview of the Provider Workflow

NextGen® Adaptive Content Engine Help Enterprise 8

Document Review of Systems Details

Open the SOAP template. In the Review of Systems panel, do one of the following: To select normal for all systems, click the ROS Defaults field, and then select default ROS from the list. To document the findings for multiple systems on a single template, click Derm ROS To document the findings for a specific system, locate the respective system on the ROS template, and then document your findings. To mark negative for all symptoms in a system, select All Neg in that system. To document the findings in detail for a specific system, click the respective system link, and then document the findings. Document the updates in the template. Click Save & Close. The option exists to save the documented information in the ROS template as the default set with a unique name, allowing you to use it again when documenting on the same template during future patient encounters. To copy the previous review of systems information to the current encounter, click ROS History. The Historical Information wi

NextGen® Adaptive Content Engine Help Enterprise 8

Review of SOAP Details by Provider

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, assessment plans, and provider communications. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan You can select the Record contains substance use disorder information check box on the SOAP template header to include the long or short form of disclosure for Substance Abuse and Mental Health Services Administration (SAMHSA) 42 CFR Part 2 provisions in the generated documents and reports. You can use Quick Notes to save the documented SOAP findings as a default set that can be used in future encounters. For more information on these settings, go to NextGen Healthcare Succes

NextGen® Adaptive Content Engine Help Enterprise 8

SOAP Template

Providers can do the following on the SOAP template. Review the patient details and add additional details. Document the presenting problems and various physical examination findings in the Physical Exam panel. Document the details of the performed procedures on the Procedures template. Document the assessments, follow-up details, treatment plans, lab orders, and office procedures in the Assessment / Plan panel. Urology-SOAP template Generate Notes Associated with Encounters You can generate the notes associated with an encounter on the SOAP template. Parent topic: Overview of the Provider Workflow

Documenting SOAP Information

Recommendations

SOAP Template

SOAP Template

The SOAP Template

Document Review of Systems Details

Review of SOAP Details by Provider

SOAP Template

SOAP Template

SOAP Template

The SOAP Template

Document Review of Systems Details

Review of SOAP Details by Provider

SOAP Template