Note: Access to the EHR features described in this article may differ for practices who have already purchased a Practice Fusion EHR subscription plan. Please contact Practice Fusion Customer Service for additional information.
1. SOAP notes
2. Simple notes (non-SOAP)
All notes in Practice Fusion will include the presence of the vital sign section as well as the Chief Complaint field. The primary distinction between a SOAP and non-SOAP note is that the SOAP note has individual sections for the Subjective, Objective, Assessment, and Plan sections, while a Simple note will have one free-text field that will serve as the body of the note.
Account administrators can create a custom Simple notes from the EHR Settings by selecting the Chart note types link. You can edit existing custom Simple notes, or click Add toward the upper right to create a new note type.
Once the note has been created, you will be able to to select it from the list of available note types when charting.
Any user has the ability to create a new SOAP or Simple note in a patient's chart. However, each user in the practice can edit different information within a SOAP or Simple note, depending on their edit level:
- Staff Edit Level- Users can create a SOAP or Simple note, but cannot edit any information.
- Nurse Edit Level- Users can enter vitals and chief complaints in both SOAP and Simple notes. They can also can edit the body of a Simple note.
- NP/PA Edit Level- Users can complete the vitals, CC, and body of a SOAP or Simple note.
- Phys/MD Edit Level- Users can complete all fields within a SOAP or Simple note and can sign encounters.
Please note that both SOAP and Simple notes count towards Meaningful Use if they have an encounter type of Office, Home, Nursing Home, or Telemedicine Visit.