New encounter notes can be created from within the Summary and Timeline tabs of your patient's chart.
Note: Staff edit levels are not able to edit SOAP notes, but can create SOAP notes, and create/edit other types of notes. For more information about edit level permission, see How do edit levels work?
Create a new note from the patient's chart
1. Open the patient's chart.
2. From the Timeline or the Summary section, click the New Encounter (SOAP) button to create a SOAP note. Alternatively, click the arrow to the right of the button to see the drop-down of other note types. *All notes that are not titled SOAP are Simple-format notes.
If an encounter has already been generated for that patient on that same day (i.e. if the patient has been checked in on the schedule), you will receive an alert to help you avoid duplicate encounters. You may proceed to create a new encounter or continue with the existing encounter.
3. Following this you will be taken to the new note. Note: If you are in the encounter, you may adjust the encounter type as needed. If not updated, it will default to “Office Visit” and count in the Meaningful Use dashboard. Proceed to complete the fields and be sure to click Save. Note: Only Phys/MD/DO edit level users may sign a note.
Returning to a note you created
After the chart note is saved or signed, you will be able to return to the note from the patient's Timeline and Summary tabs.