The Objective section of the SOAP includes all the information that you observe or measure about the patient. This section covers vital signs and measurements (such as weight), findings from physical examinations, results from the laboratory, and other diagnostic tests already completed.
π All entries are automatically saved.
π Clicking the Finalize button updates the record from Draft to Open and generates a unique record number.
Vitals
The Vitals section records key health metrics like weight, temperature, heart rate, respiration rate, body and muscle condition, pain score, hydration, attitude, behaviour, mucous membranes, and capillary refill time (CRT), with space for additional notes.
β The new Vitals Widget is now available in Beta, and will be soon launched for everyone.
How to Use the Vitals Table Widget:
Accessing the Widget:
Navigate to the Objective tab within the patient's SOAP record.
Open the Vitals section.β
Recording Vitals:
Click on the "Add Vitals Entry" button.β
Enter the necessary details such as weight, temperature, heart rate, respiration rate, and other relevant metrics.β
Repeat the process to add multiple entries as needed during the visit.β
Viewing Graphs:
After entering the vitals, the system will automatically generate graphs displaying the trends of the recorded metrics.β
These graphs can be viewed within the Vitals section and provide a quick visual overview of the patient's vital signs over time.
The old version of the Vitals contains all the relevant fields, depending on your SOAP Templates.
Clinical Examination
The Clinical Examination section allows you to document a comprehensive patient assessment by selecting from predefined categories, including Eyes, Ears, Mouth, Skin/Coat/Nails, Lymph Nodes, and major body systems such as Digestive, Respiratory, Cardiovascular, Musculoskeletal, Neurological, and Urogenital. Each category provides relevant fields to ensure a thorough examination:
Click on the Clinical Examination tab, within the Objective section
Check the box(s) next to the category or categories you need
Enter the information in the displayed custom fields below:
Lab tests / Investigations
The Lab Tests/Investigations section allows you to document and manage diagnostic tests across various categories, including bloodwork, imaging, microbiology, and specialized exams. Each category provides relevant fields to ensure accurate test documentation:
Open the Lab tests/Investigations section within the Objective tab
Check the box(s) next to the category or categories you need
Enter the information in the displayed custom fields below
Body Maps
Add Body Maps to visually track and annotate your patient's condition:
Open the Objective section
Click on the Body Maps tab
Click on the + Add Body Map button in the top right
Enter the name of the body map within the Search box
Check the box next to the body name
Hit the Confirm button
You can save the map to your files (i.e. Save to Files) or Print it:
Click on the body map hyperlink below Name
Hit the Save to Files / Print button depending on the action you wish to take
π‘Learn more on how to create and manage body maps here.
Files
The Files tab allows for easy uploading and management of various documents, ensuring all patient records are organized and accessible:
Go to the Objective section
Open the Files tab
Click on the Upload Files button
Use the buttons under the Actions tab to download or delete your files:
