How to Create a SOAP Note for a New Patient

How to Create a SOAP Note for a New Patient

To create a SOAP note for a new patient visit, the patient has to be on the Appointment Scheduler. There are two ways a new patient appears on the Appointment Calendar/Scheduler: 

You're using zHealth Online Appointment Portal and a new patient books an appointment.

You're not using our online appointment booking portal. In this case, you will have to manually add the new patient to the Scheduler for a given slot

Click here to know 
how to book and schedule a new patient.

Once you book a new patient or you have a new patient booked on a given time slot and date through our online appointment portal, all you have to do is follow the given instructions.

1. On your Calendar, search the patient name and click on the small 'Gear' icon. A pop-up window opens.

2. Click 'Check-in' to check-in the patient. The window will refresh and you can see blue circle in front of the patient name, which indicates the patient has been checked-in. This helps to create a new SOAP note for today's date.
Note: a. If the patient has checked-in using Patient Portal, you will not have to manually check-in the patient then. The blue circle will appear as soon as the patient checks-in online through the patient portal. In this case too, a SOAP note is created when patient checks-in online.

b.  If there is no open note and you click the "SOAP Note" tab that has the date on it (either today's date or the last open note), this will open a new note for today. This will also check a patient in if they are on the schedule for today and haven't been checked in already.

c. If you click "New Note", it will open a new note for today if a note isn't already open. This will also check a patient in if they are on the schedule for today and haven't been checked in already.

3. Now once the patient has been checked-in. Click on the patient name on the Appointment Scheduler to open the Patient Chart.

4. You will be redirected to the Summary section of the Patient Chart. Just below the Summary section, you will see a new note created for today's date.

Click on the
Edit button. You will be redirected to the SOAP Note section where you can enter Exam, Plan, Assessment, and Daily Notes for the patient's visit.

5. Start filling in the SOAP details:
a. On the left panel of the SOAP Note window, there are different SOAP components. Click on each tab to add:
  1. Subjective
  2. Pain Diagram
  3. Objective
  4. Assessment
  5. Plan

If you have other details to add like Exam, Daily Notes, Acupuncture, Additional information, click on respective tabs and fill in the details.

b. Click on the Date box to change the date if required. The Date box is available in each SOAP component, including Subjective, Objective, Assessment, Plan as well as Exam, Daily Notes, Additional, and Invoice.

c. On the Comments box, add any comment if necessary. The character limit for the Comments box is 200 characters. The Comments box is available in each SOAP component, including Subjective, Objective, Assessment, Plan as well as Exam, Daily Notes, Additional, and Invoice.


Pain Diagram




6. Once you're finished with all the SOAP note sections, go ahead and create an invoice for the patient visit. 

7. Once you've created an invoice, send this invoice to the patient via email to enable the patient to pay online. You can even ask the front-desk staff to collect patient copay or outstanding balance using zHealthPay Payment Terminal. Now, you can go ahead and click "Checkout" in the SOAP Note section. The patient will be checked out.  Note: The Checkout button stays in the SOAP note section even when Invoice is clicked.

If you want to submit the claim right after every patient visit, you can click "Submit Claim" in the SOAP Note section. Verify all patient details, visit details, and other information before submitting the HCFA form.

We recommend adding Contact Details and Insurance details of a new patient before creating an invoice for the present visit.

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