How to Use the Self-Service SOAP Notes Builder (Beta now available)

If you are interested in testing out this new functionality, please reach out to your Customer Success Specialist or support@zhealthehr.com.

zHealth’s Self-Service SOAP Notes Builder (SSSNB) gives you the ability to create your own custom SOAP note templates.

And here's how you can use the tool to build your SOAP note:

Watch Video: How to Customize Your Own SOAP Notes

Read Step-by-Step Instructions: How to Customize Your Own SOAP Notes

1. Go to Customize Your SOAP Note Dashboard To create a new SOAP note, head over to your Dashboard. Hover the cursor over your name on the top right corner. Click on "Customize SOAP Notes." You will be directed to a new tab. On the new tab, click on "Let's get started" to start building your own templates.

2. On the next screen, you have an option to build your template from: a. Start from Scratch (Start Building Your Own SOAP Template From Scratch) b. Use Pre-Built Templates (Start Building Your Own SOAP From Pre-Built Templates)

a. Building a template from scratch

1. If you choose to build your template from scratch, you will be directed to the next screen where you need to enter the name of Screen (such as Subjective, Objective, Assessment, Plan, others.) Enter the name of the screen and click "Create".

2. Next, you will see the SOAP notes builder area where you can drag and drop elements to build your template from scratch. a. Elements - Drag and drop the elements you want in your notes b. Template Name - The template name will be shown at the top of the builder c. Clear All - If you want to clear all elements from the notes and start again, click this button and all elements will be cleared at one go. d. This is the area where you need to drag and drop elements one by one e. Preview and Save Form - Click this button to preview and save your template   Note: Check the section "Elements in the SOAP Notes Builder" section to learn the functions of these elements.

b. Building your SOAP notes using pre-built templates

1. If you choose "Use Pre-built Templates", you will be directed to the next screen where you can see various pre-built templates for Subjective, Objective, Assessment, Plan, Exam, and Others. Click on each section (Subjective, Objective, Assessment, Plan, Exam, and Others) to view all the available templates.  To view how each template looks like, click on the templates shown for each section.

2. To access a template, simply click on its name. Then, click on the drop-down arrow icon next to the name to view its design. After reviewing the template and if you decide to to use it, click "Load Design to your Dashboard". Once you click the button, you will get a message - "Pre-built template design is loaded as a new section in your builder." Click the cross icon to close it. Similarly, if you wish to select more templates from Objective, Assessment, Plan, Exam, and Other sections, browse the available templates and click "Load Design to your Dashboard". Now, entire sections with multiple sub-sections can be saved as pre-built templates. You can choose any pre-built template, which will then be loaded as a new sub-section in your SOAP Notes Builder dashboard.

3. The templates you selected will be loaded. Click the "Back to Dashboard" button at the top right corner. You will be directed to the SOAP Builder Dashboard where you can see all the sections and templates you selected. You can take the following actions: a. This is section names, such as Subjective, Objective, Assesssment, Plan, Exam, etc. b. This is the template inside the highlighted section. Click the pen icon to edit the name of the template. c. Click the eye icon to view the template d. Click the edit icon to edit the template design e. Click the four-arrow icon to move the template up and down when you have multiple templates in each section f. Click the "Add Template" button when you want to add more templates in each section. g. Click the "Pre-Built Template Designs" button to select from available templates and use them in your SOAP notes h. Click the "Save As Pre-Built Template Design*" button when you want to save your templates in a particular section. *Note: You cannot revert this action and need to contact development team to delete it

c. Building your second template and so on...

1. Add a New Section When you want to build you next template, follow these steps: Create a new SOAP Section by clicking "Add Section" button. Give a name to the Section like Subjective, Objective, Assessment, Plan, or Exam.  Once you name the Section and save it. Close the pop-up window.

2. Choose from two options As soon as you name the Section, you will get two options to create your own Template: a. Build a Template from Scratch b. Build a Template using Pre-Built Templates

3. Build from Scratch If you select "Build from Scratch", you will be redirected to Builder where you can: a. Drag and drop form elements from the left panel to the blank space. b. If you decide to use Pre-Built Templates, click the button at the top and choose your template to proceed. c. You can Preview and Save the Template with the "Preview and Save Form" button. d. To clear the entire form and start again, click "Clear All" at the top right corner.

4. Use Pre-Built Templates If you want to use "Pre-Built Templates" at Step 4 above, you will be directed to this screen as shown here. a. To view pre-built templates in each Section, click the options on the Left Panel b. The corresponding templates available under each Section will be displayed on the right side. Click on the Template to preview it. If you want to use any template, click "Load Template" at the bottom of the Preview screen. Once you load a template, you will get a message "Template loaded successfully." Close the message box and you can see the pre-built template on the Builder Screen as shown in the third screenshot here.

5. To make changes to Sections or Templates a. To rearrange a Section, edit the name, or delete a section, click the corresponding icons. b. To preview the template, edit the template's form elements, delete a template, or rearrange the template order, click the corresponding icons. By default, the first Template you will create under each Section will have the same name as your Section. To rename a template, click the "Pencil" icon as shown in the second screenshot here and edit the Template name to something like "Vitals", "Neuro Exam", etc.

Elements in SOAP Builder - How They Work

1. Label: This functions as a heading within a template. It allows users to put a heading to new segments, such as lower extremity or upper extremity, helping you to differentiate between different inner segments.

(i). To add a label, drag and drop the Label from the left panel to the builder area.  Once you add the label, enter a name for the Label.  You can delete the label by simply clicking the red cross icon.

2. Button: This element is a text button that is capable of accommodating up to 23 characters. These buttons turn green when selected. You can specify the number of rows and columns; for columns, a maximum of 9 buttons can be accommodated, while rows have no specific limit.

(i) To use Button element, simply drag and drop it from the left panel to the Builder area. Once you add the Button, type your label.  (ii) Click the green "#" icon. A pop-up window opens. Specify the number of rows and columns; for columns, a maximum of 9 buttons can be accommodated, while rows have no specific limit. Select your narrative layout, whether you want horizontal or vertical layout. Click "Save". (iii) Once you save the settings, you will see buttons are added according to the number of rows, columns, and narrative layout you selected. Now, add button names. There are couple of other things you can do: a. Click the '-' icon at the top to delete any column you want. b. Click the '-' icon at the right side to delete any row you want. c. Click the '*' icon to customize your findings in the SOAP note. (Type what you want the findings to be shown and click save)

3. Text: Use this fixed-size textbox to input short answers.

(i) To add a text, simply drag and drop the text element from the left panel to the Builder area. a. Add a label to the text b. Click the + icon to add more textbox c. Click the yellow x icon to delete any textbox d. Click the red cross icon to delete the entire textbox element.

4. Textarea: An expandable text area for creating customized encounter notes.

(i) To add textarea, simply drag and drop the element from the left panel to the Builder area. Once you add it, type your label for the textarea. You can click the * icon to customize findings. Type the findings and click Save as shown in the second screenshot.

5. Checkbox: Use this feature when you need to select multiple options.

(i) To add a checkbox element, simply drag and drop it from the left panel to the Builder area. Type your label for the checkbox and enter the checkbox name. Click the + icon to add more checkbox options. Click the * icon to customize findings. Click the yellow cross to delete any single checkbox option or the red cross icon to delete the entire Checkbox element.

6. Select: This element allows you to select create a dropdown option where patients can select only one option from a list of multiple choices, optimizing space usage.

(i) To add a Select element, simply drag and drop it from the left panel to the Builder area. a. Type your label b. Click the green # icon to open the settings for creating a dropdown. A pop-up window opens. Click "add option" to add multiple options. Enter name for each option. Lastly, click Generate Dropdown. c. Click the + icon to add more dropdown options.

7. Radio: This works similar to Select element. Use this option when you need to choose only one option from among multiple choices in the form of a Radio button.

(i) To add a Radio element, simply drag and drop it from the left panel to the Builder area. a. Type your label b. Enter the radio button name. c. Click the + icon to add more radio button options. Click the * icon to customize findings. Click the yellow cross to delete any single checkbox option or the red cross icon to delete the entire Radio element.

8. Record: Utilize this element to voice-dictate your SOAP note.

(i) To add a Record element, simply drag and drop it from the left panel to the Builder area. a. Type your label b. Click the * icon to customize findings.  c. Click the red cross icon to delete the entire Record element.

9. Date Picker: Choose this option to collect dates such as the date of an accident, onset of symptoms, or date of surgery.

(i) To add a Date Picker element, simply drag and drop it from the left panel to the Builder area. a. Type your label b. Click the * icon to customize findings. c. Click the + icon to add more date picker boxes. d. Click the red cross icon to delete the entire Date Picker element.

10. On Off: This is a toggle button element that allows you to select multiple options. By toggling to the right, the option turns green.

(i) To add an On Off element, simply drag and drop it from the left panel to the Builder area. a. Type your label b. Click the * icon to customize findings for each toggle option. c. Type the single toggle button name/ d. Click the X icon to delete a single toggle option e. Click the + icon to add more toggle options f. Click the red cross icon to delete the entire On Off element

11. Double Sided Checkbox: Utilize this element when you need to select options for both left and right sides, such as thoracic, cervical, and lumbar regions.

To add a Double Sided Checkbox element, simply drag and drop it from the left panel to the Builder area. a. Click the green # icon to open settings. Choose Narrative Layout - Horizontal or Vertical. If you select Vertical, you will need to enter the number of rows and columns. A double sided checkbox can accommodate a maximum of 3 columns, but there no limitations for the number of rows. c. Check the third screenshot. In horizontal layout, you can click the + icon to add more options. In Vertical layout, you will see 3 columns with description labels. You need to also enter the label name for each option. A good use case of this element is when you need to show pain location for T0, T1, T2, or C1, C2, C3, etc.

12. Nested Element: This feature allows for the inclusion of multiple elements within a single container, such as checkboxes, text fields, and more.

To add a Nested Element, simply drag and drop it from the left panel to the Builder area. a. Click the green # icon to add multiple options you want. A pop-up window opens. Select the options you want and then click x icon to close the pop-up window. b. Click the * icon to customize findings. c. Click the red cross icon to delete the entire Nested element.

Note 1: If the Section created by a clinic is mapped, it will show a different pop-up for the mapped Sections. And, when deleted, it will be unmapped from the organization and from the frontdesk as well.

Note 2: If there are unsigned notes, then you will get a pop-up message and a button to sign the notes. Click the button "Sign Open Notes" on teh pop-up window to sign the notes. The 'Click to Finalize' button will always be present even if there are unsigned notes. So, iIf you have unsigned Notes, you will get an alert message like this in SOAP Builder Dashboard "ALERT: There still are 3 unsigned notes, please sign them to continue finalizing your SOAP customization!" 

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