Episode Problems and Episode SOAPS

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, right click the header and choose Add New Element, then click on Add Problem to open up the Episode Problem list. 

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Patient Record - Add Problem

A new Add Problems window will open in the Patient Record. The episode that you are adding this problem to will appear at the top of the window so you can make sure it’s going in the right place.

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

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Add Problems to Episode Window

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

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.    For the purpose of the GSP Labs, your Subjective and Objective writing will be the same on each day for all problems. (In real life practice, this may be different depending on the case.)

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 appear something like the example below.

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. Click on the Merge icon on the problem to join two Problems into a single unified issue.

Select the existing Problem from the drop down list and the overlapping problem will be merged in to the selected Problem when you click on the check mark icon to the right. You can repeat this process for as many Problems as you want to merge together.

Merged problems will be labeled on the SOAP to avoid confusion. Any previously added sections will still be visible, but you should not add new sections to a problem that was already merged.

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.

This button will reopen the Problem’s drop down menu and let you choose a new one. (If Free Text is turned on, you can manually write in the Problem name.)

If you hit the Rename button in error, you can also cancel out to stop the change.

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 All 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.  You can also this for your own notes on the case that aren’t part of the SOAP. However, comments are visible to everyone, and can still be submitted for review if you want to ensure your supervisor sees them.

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.