Create a SOAP Note

Permissions: Therapist can create Notes for their assigned Cases, Administrators or higher can create Notes for all Cases.

SOAP Notes must be enabled for your Organization before you can create one.  Once enabled, there are several way to access and add a SOAP Note for a Client. This is the My Clients Plus recommended workflow as it will link your SOAP Note to a Client Appointment. 

Jump to Section [Add SOAP Note] [Complete SOAP Note]

Add a SOAP Note

1. Be sure an Appointment has been created for this Client.
2. On the Schedule, navigate to appropriate Client Appointment.
3. Click Add Progress Note button. 
4. If Client has no Cases, click drop down and select SOAP Note.
5. Click Create Note.
   
   
   
6. OR, if a Case is already created, click Case Info for appropriate Case.
7. Click Progress Notes tab and then + Progress Note button.
   
   
   
8. Select Soap Note from the drop down and click Create Note.
   

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Complete a SOAP Note

Once the SOAP Note has been added, add the appropriate information to complete and Save the Note.

1. The Appointment and Place of Service will auto-populate upon creation.
   

   NOTE: If you have proper permissions you can change the Place of Service on the Note. 

2. The Duration In Minutes field autofills with the Appointment length. If it was shorter or longer, edit that here. 
3. The Provider(s) on the Appointment auto-fill. You can add/remove any Staff Member who is assigned to the Case or already on the Appointment. 
4. Enter Mental Status and Risk Assessment. Type in the field and select from list or enter in a new phrase.
5. The Diagnostic Impressions from the Initial Assessment & Diagnostic Code tab and a History of Treatment Goals display. Click the Treatment Plan tab or the Initial Assessment & Diagnostic Codes tab to edit.
6. Select Type of Note and enter Participant(s) in Session.
7. As you fill in the Note, your draft auto-saves and will display a message in the top right corner.
   

   NOTE: If you leave the page without pressing the green Save button, you can still retrieve the Note by clicking View Draft Copies of This Note. Loaded drafts disappear after the Note is finally saved. Click here to read more about document drafts in My Clients Plus.

8. When you have completed the note click the green Save icon.

Related Articles: Set SOAP Note as Default Note Type

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