Record overview

Let's review what information is included in each section of the SOAP.

Sophia avatar
Written by Sophia
Updated over a week ago

The record is divided into 6 different sections. Let's have a look at them! πŸ‘‡


1. Summary

Details

Here you can find the general details of the record, such as the date, services, and staff members. All this information comes prefilled, so you only need to update it when something changes.

There is space for internal notes as well - these are visible only to your practice and won't be shared with the client.

Treatment Plan

Create treatment plans (estimates) and sync them directly in the Record.


2. Subjective

Initial Complaint

There are 2 fields in this subsection: one comes from the appointment requests, so all the details that the clients are writing will be displayed here, while the second field is a general one for notes taken in the practice.

History

Here you can include all the questions you normally ask in the first part of the consultation. From activity level to the last meal time, you can customize the record depending on the type of the visit.

Read more about this section here.


3. Objective

Vitals

From temperature, pulse, and respiratory rate, to body condition and attitude.

Physical Exam

This subsection is divided into more categories, so depending on the visit, you can go through different systems such as Ophthalmology, Respiratory, Cardiology, and many more.

Laboratory / Investigations

Here you can record the results of the internal or external investigations.

Documents / Files

Easy upload of any type of document.

Read more about this section here.


4. Assessment

This section contains everything regarding provisional and final diagnoses.

Read more about this section here.


5. Plan

Services & Products

Everything regarding performed services and administered products goes here.

Procedures Reports

Here you can go more in-depth into the procedures performed.

Prescriptions

Check out how to generate new prescriptions or fill medications here.

Recommendations

You can set up predefined recommendations for diagnoses and products. Every time you use them, this section will get updated. You can also add new ones or write general recommendations.

Follow-up Appointment

Don't let clients leave without the next appointment! Here you can directly schedule the next visit for them.

Read more about this section here.


6. Billing

In Digitail, the invoice is created automatically! All the services and products used in the Plan section will directly appear on the invoice. In this section, you can add extra products, offer discounts, and record payments.

Read more about this section here.

You can view a video overview of the SOAP feature here.

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