Creating a SOAP Note
For therapists/counselors needing to utilize the SOAP note format in their progress note, custom buttons can be utilized with great efficiency. This knowledge base article will provide step-by-step instructions for creating a SOAP note button (or series of buttons) in both the Classic and New Therapist Progress Note, as well as the Case Management/Social Worker progress note, and will outline the workflow for completing a SOAP note using ICANotes' built-in content.
Creating Custom SOAP Buttons
Start by selecting your note type.
In the New version of the Therapist progress note, locate your custom buttons to the right of the screen, then click Create Therapy Note Button.
In the Classic version of the Therapist progress note, locate your custom buttons to the left of the yellow text field, then click Create New PN (Non-Rx) Button.
In the Case Manager/Social Worker note, locate your custom buttons to the right of the screen, then click Create New Button.
In the Add a Custom Button pop-up window, you'll give your custom button a name (step 1), enter the text you want the button to contain in "variation 1" (step 2a), and set the sharing options (step 4) before clicking Continue to save.
You may want to create your SOAP note template in one button, or break it up into multiple buttons (one each for S, O, A, and P). Below are examples of each:
Example 1: Creating the SOAP note format in one button so that clicking on it produces the full template for each portion of the note
Example 2: Breaking up the SOAP format into multiple custom buttons (one each for S, O, A, and P), so that each section can be completed in turn
New Therapist Progress Note
Subjective: Start with the Clinical Status/Complexity, and/or type the patient's statement, quote, or a paraphrased statement.
Objective: Use the Mental Status Exam/Appearance section to fulfill the Objective. You may also free-text this area.
Assessment: You can free-text additional information, but letting the program populate the Diagnosis will meet basic SOAP criteria. The Diagnosis work area is in PN, Part 2 of the note.
Plan: Use the Link to Treatment Plan button in PN, Part 2 to include selected goals and interventions from the Treatment Plan into the progress note.
Progress and Plan options are available for inclusion as well.
Classic Therapist Progress Note
Subjective: Start with your Clinical Status/Complexity (click Start Here) and/or free-text a statement, quote, or paraphrased statement from the client.
Objective: Use the Mental Status Exam/Appearance to fulfill the Objective.
Assessment: You can free-text additional information, but letting the program populate the Diagnosis will meet basic SOAP criteria.
Plan: Use the Link to Treatment Plan or Create a Custom Instructions Button. Progress in meeting goals and recommendations/plan options are listed under the Treatment Plan problems/interventions that have been linked into the note.
Progress and Plan options are available for inclusion as well.
Case Manager/Social Worker Note
Subjective: Free-text a statement, quote, or paraphrased statement from the client.
Objective: Use the Appearance and Behavior sections on the left side of the screen in ICANotes' built-in content, or the MSE/Appearance and Behavior buttons to the right of the yellow work area.
Assessment: You can free-text additional information, but letting the program populate the Diagnosis will meet basic SOAP criteria.
Plan: Use the Link to Treatment Plan or Create a Custom Instructions Button. Progress in meeting goals and recommendations/plan options are listed under the Treatment Plan problems/interventions that have been linked into the note.
Progress and Plan options are available for inclusion as well.
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