How do I edit an existing SOAP or Simple Note?

How do I edit an existing SOAP or Simple Note? 
You may edit an existing encounter or simple chart note if the note has not been signed. NP/PA or Phys/MD/DO edit level users may edit existing SOAP notes. Nurse edit level users and higher may edit Simple notes. 

Edit an existing SOAP or Simple Note
1. Open the patient's chart.

2. Navigate to the patient’s Timeline and select Encounters from the drop-down menu.


3. Click on the note to open the encounter.

4.  If the encounter is unsigned, you will be able to edit the encounter by clicking into the fields. You may use the "Go to..." feature at the top left of the encounter to quickly navigate to the section you want to edit. You may also use rich text editing when completing your encounter. For additional information, see: How do I utilize rich text editing?

5. Click on Save when you complete your work.

Delete an unsigned encounter
An unsigned encounter can be deleted if necessary by clicking Delete from the Actions drop-down. Note: If you do not see the "Delete" option, it is most likely related to Edit Level Permissions

 

You will be prompted to confirm that you want to delete the note to ensure that it is not deleted in error.



Edit a signed SOAP or Simple Note
An encounter cannot be edited after it has been signed. The act of signing a chart note renders the note a legal document. A signed encounter will be marked as signed in the patient's Timeline:  


To add additional information or make a correction to a signed SOAP or Simple note, add an amendment/addendum to the note. Only Phys/MD/DO edit level users may add an amendment/addendum to a signed chart note. 

Add an amendment/addendum to a Signed SOAP or Simple Note 

1. Open the patient's chart

2. Navigate to the patient’s Timeline and select Encounters from the drop-down menu.

3. Click on the note to open the encounter

4. The Add addendum button will appear in the top-right corner when viewing a signed encounter.


You can then add information based on comments or input from the patients or providers as well as information provided through a referral. 



Note: A saved addendum cannot be edited.

Please note that if you have the same encounter open in different tabs and sign the encounter in one tab, you will receive an error message if you try to add a medication or diagnosis to the encounter in the other tab. You will not be able to add any additional information to this locked note and it will be refreshed, allowing you to review the most up-to-date version of the encounter.


Charting

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  3. How do I complete a chart note?
  4. How do I use rich text editing when charting my encounters?
  5. How do I add diagnoses to a patient chart?
  6. How do I add a medication?
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  36. Why am I receiving the error "Unable to sign" when trying to sign a chart note?
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