SOAP Notes – handwritten vs computer-based
Please Note! Due to the high volume of irritating spam and slow-down of participation here, we are no longer accepting new comments, questions, or subjects on this Forum. We are keeping all the subjects and comments for review as there is a lot of good stuff here relating to practice-building subjects. So, dig deep! Thanks to everyone who participated here but it is time to move on to bigger projects educating the public about acupuncture! Matt Bauer
07-Feb-2013 10:53 AM
Awhile back you were kind enough to send me a sample of your SOAP notes and I kept meaning to ask… I see they are in typed format. Are you typing them up after each visit, or dictating them for someone else to type? Do you use patient management software or are you using Word? And with the typed notes, are you printing them out for the chart to have in the room during treatment or just on the computer?
I’m still handwriting everything, and would love to be more computer based since I type faster than I write, but I just haven’t switched. I would love to hear from you as well as anyone else who has been doing computer charting rather than handwritten. Thanks!
07-Feb-2013 01:19 PM
I am typing into a Word document and then print that off a laser printer with a fron page feeder. I went to this because my writing was so bad my notes were not legible. So I type my notes, print, then erase the Word doc (except the date) and repeat throughout the day. I have a template chart doc that has the lines numbered down the length of the page so I can gauge how far down I need to go to space the new notes just below the previous treatments notes. It is a bit funky but functional. I expect to eventually go to all electronic but am sort of waiting for things to get to the point that others can show me how to do that easily.
09-Jun-2013 09:55 AM
|I use Practice Fusion- it’s free and web-based. It’s in an easy to use SOAP format. I’ve been using it for about 6 months and so far so good. No need for file cabinets anymore. |
09-Jun-2013 07:24 PM
|Hi Matthew, |
Thanks for starting a forum like this!
I started electronic records with Office Ally’s EHR, but it was $30/mth and difficult to use.
1. Yes it’s HIPAA compliant. A lot of doctors use it.
2. I was pretty resistant at the beginning. I started by taking notes on paper then entering it on my computer later. I still printed them and kept a paper file for a while, but that got even more time consuming and defeated the purpose I figured.I now have a MacBook Air I take into the treatment room with me and it’s been great. Practice fusion also has a beta iPad version, but I haven’t tried it yet. All of the patient’s chart notes, past medical history, allergies and medications are available at the click of a button on the side of the screen. It’s easier to use than I ever thought. You can set up templates (like review of systems questions,etc).
3. If the Internet is down….you’re out of luck. 🙁
4. I actually scan the new patient paperwork and upload it to practice fusion as a document. I have also scanned all the old chart notes and uploaded those so I can be completely paperless. I also scan labwork, medical records, insurance card and verification info.
The only thing is that I remember what I write easier than remembering what I type – but I review the chart before the appointment so it works out ok.