Episode Problems and SOAPs (JRS/GSP)

The Problem List and SOAPs section allows you to add in episode problems, which can then be linked to the patient's master problem list.  It also allows you to complete a SOAP for each identified episode problem(s).

For this course you are only required to complete one Subjective and Objective for each day. However, every problem will need their individualized Assessment and Plan.

Adding Episode Problems

From the Patient Record Visit Information tab, click on Add Problem to open up the Episode Problem list.  If no problems have been added before, this will be available under the right click menu.

The episode that you are adding this problem to will appear at the top of the window.

You may select from the drop down list or if your problem is not present you may enter a new one via free text.

You can enter as many problems as you want on this window.  You can also add additional problems later.  

Click on the Save button to add the problems to the episode.

You can remove any of the problems you added before you click on the Save button by clicking on the red X.  You can also edit the text to clarify before clicking on Save.

Creating SOAPs

Once you have added Episode Problems you can begin to SOAP the problems.  

Hover over today’s date and add the Subjective and Objective, at the day level.

This will open a text field.  You can begin typing in your Subjective observations in the S field, and the Objective (numerical data) in the O field.   

Once you enter your text for each section, save your work by clicking the green check in the header section.  Text will also auto save periodically, to avoid the potential for any loss of work.

Your instructor will provide the recommended text format for this lab. 

After saving your daily Subjective and Objective you can begin your Assessment and Plan for each problem.

Hover over each problem to add the Assessment and Plan.

A completed SOAP may look like the below record.

Merging Problems

If multiple problems have been identified to be related (e.g. symptoms of the same underlying disease) you can Merge the problems within the episode.

First, add your newly identified Problem.

Then, hover over the previous Problem you are wanting to roll into your newly identified problem. Click the Merge icon, which looks like two lines joining together at the top.

You will be able to select your new Problem from a drop down list and the previous problem will be merged in to the selected Problem.

Click the tiny green check mark to save your merge.  Or click on the small ban sign (circle with a line through the middle) to cancel out if you selected the wrong problem.

You can repeat this for multiple problems if necessary.

Your Problem section will now display like the below.   Any SOAPs entered for the problems will remain visible. 

Renaming Problems

If a Problem has been inappropriately named, you can hover over the Problem and select Rename Problem (icon that appears like a small tag.) Note: It is not advised to rename a previously merged problem - instead add the new problem and merge the old, previously merged issue again.

Click on the small check mark to complete the process.

Submit for Review

If you have been asked to submit your work to your supervisor to review, this can be done by clicking on the Submit for Review button on the header, the problem, or the individual SOAP sections.

Add Comments

Your supervisor or your lab partners can add comments to a SOAP. 

Print SOAPs

If you are asked to print your work, this can be done by clicking on the Print SOAPs button (printer icon) on the header bar.

This will open up a PDF version of the SOAPs report which can be sent to any network printer, or saved to your laptop for later printing.