SOAP (Subjective, Objective, Assessment, Plan) records are an essential part of any veterinary practice, helping you document patient encounters systematically and thoroughly. Digitail allows you to create SOAP record templates, streamlining the documentation process and ensuring consistency across your practice.
This guide will walk you through the process of creating SOAP record templates in Digitail, allowing you to customize and optimize your workflow, reduce redundancy, and maintain high-quality patient records.
Creating SOAP/Record Templates
From the administrative view, go to Templates located in the left toolbar. Click on Add New, or Duplicate an existing template. If you need to Edit or Delete a template, simply click on the icons from the Actions column.
Begin by giving your template a descriptive name. This name should reflect the purpose of the template, such as "Routine Check-Up" or "Dermatology Visit." A clear and specific name will make it easier for you and your team to select the appropriate template for each patient visit.
Next, you’ll be able to customize each section of the SOAP template.
You can decide if you want to hide or show a specific section only under certain conditions (for example, just for dogs, or for animals between some ages).
Summary Section
Here you can predefine services, staff members and include internal notes. The notes are always private and you can use the space to describe procedures, remind colleagues of something, etc.
Subjective Section
In this section, consider including fields that capture essential patient history and symptoms. You might add text boxes for general history, presenting complaints, or any recent changes in the pet’s behavior. If certain questions or prompts are commonly asked during patient intake, include them here to ensure consistency.
Objective Section
For the objective portion, include fields for vital signs, physical exam notes, and diagnostic results. You can create predefined fields for common measurements such as temperature, pulse, and respiration, or leave space for free-form text if you prefer more flexibility.
Assessment Section
The assessment section might include fields for diagnoses, differential diagnoses, or interpretations of the objective data. Depending on the nature of your practice, you might want to include dropdown menus for commonly encountered conditions, making it quicker to fill out this section.
Plan Section
Finally, in the plan section, outline the treatment options, medications, and next steps. You can include checklists for standard treatments, space for medication instructions, and reminders for follow-up visits. Additionally, you can add a field for client education notes or discharge instructions.
If you want to hide a section, simply click the toggle switch to the off position and the entire section will be greyed out.
If you want to show a section only under some conditions, click on the gear icon and configure the rules. Once you save the conditions, the gear icon will turn a darker color so you can easily spot which sections or fields have special display rules.
📌 You can customize fields based on:
Species
Age
Weight
Gender
Reproductive status
You can apply these settings for the main sections (Subjective - Objective - Assessment - Plan) or for any other subsection or field from the Record.
You can also define specific values for any of the fields so you don't need to type and lose precious time. This is helpful to set default templates for normal values or for abnormal ones.
Saving and Managing Your Templates
Once you've designed your template, click Save to store it in your template library. Your new template will now be available for use whenever you create a SOAP record. To use a template, simply select it from the list when you begin documenting a new patient visit.
You can also manage your templates by returning to the SOAP Templates section in the settings. Here, you can edit existing templates to reflect changes in your practice's protocols, duplicate templates for variations, or delete templates that are no longer in use.
Using Templates in Records
When creating a new Record, you can select one of the templates you've created. You'll see the template being applied immediately - only the sections and fields that you decided to show will be visible and all the fields that had predefined values will be already selected/prefilled. You can change any of the default values or add new ones.
📌 While the Record is in Draft mode you can change the template, but once the Record is saved you won't be able to update or remove the associated template.
Best Practices for Using SOAP/Record Templates
To get the most out of your SOAP record templates, consider the following best practices:
Keep it Simple: While it's important to capture all necessary information, avoid overloading your templates with too many fields. Focus on the essentials to make the documentation process as efficient as possible.
Regularly Update Templates: As your practice evolves, so too should your templates. Regularly review and update them to ensure they align with current practices and standards.
Train Your Team: Make sure all team members are familiar with how to use the templates. A well-trained team can use templates to maintain consistency and reduce errors in patient records.
Customize for Different Visit Types: Create different templates for various types of visits or cases. For example, you might have a specific template for wellness exams, another for surgical follow-ups, and another for emergency visits.