Are you a veterinary specialist practicing in Ophthalmology, Dentistry or another domain? See how you can tailor Scribenote's SOAP notes to fit your documentation needs.
We recently introduced a new feature to Scribenote, allowing you to customize your notes and templates so they can better fit your documentation patterns, no matter which specialty you practice. This was our most requested feature so far, and we're proud to say it's finally ready! So let's dive in and take a look at how you can set up custom Scribenote SOAP notes and templates for your practice.
In this guide, we'll be using the example of a typical Ophthalmology note.
Creating a Custom Template
Starting off on the Dashboard, navigate to the Templates section.
You'll see all of the preset Scribenote templates, as well as your custom templates underneath. If you're just starting out with Scribenote, your screen will look like this as you won't have any templates here yet. Let's create one together!
Click the + New Template button.
Fill in a name, description, and choose a colour for your custom template.
Now here's where it gets interesting: we can start dealing with the SOAP fields. As this is just going to be a generic template, we can leave the Subjective field blank. You'll be able to fill this in with data when you apply this template to a note.
Let's take a look at the Objective section:
As you can see, by default there are Objective fields categorized into Vitals, Systems, and Overall. With Scribenote's new custom Objective fields feature, you can add or remove fields to your liking, and even use a completely blank objective field if you need to.
Toggle the Edit Fields switch.
You'll notice there's now an + Add New Field button at the bottom of the section. You'll also see that there is now a delete icon next to each default field. Let's start off by deleting all the default fields, except for Overall.
Click the remove button next to each field until the section looks like this:
Now we can go ahead and start populating our custom fields.
Click the + Add New Field button.
You'll see a blank line appear with three sections.
You'll need to fill in 1) the field name, and 3) the field symmetry (if applicable). If there's any standard value for this field, then you would fill out 2) as well.
In our case, these fields will all have symmetry, so click on the symmetry dropdown and select OS/OD. You'll notice the field value 2) splits into two sides.
Add the following fields as shown:
Please note, this is just a typical example and has been adapted from the CVO's sample opthalmological chart. If there are additional fields you require in your case, you may also add them to your custom fields.
Toggle Edit Fields off.
That's pretty much all there is to it! From here, if there is any standard data you would like to add to any fields, please do so now. For tutorials sake, I'm going to enter some info into the Plan section.
Save the template by clicking Save Template → at the bottom of the form.
After saving, you should be directed back to the Templates page, where you will see your newly created template in the Your Templates section.
Next, we're going to use this template for creating a SOAP note.
Click the Quick SOAP button in the navbar.
Note that if you would like to create a note for a specific patient, you can go to the account drop-down > New Note > Patient Note > select the desired patient.
Creating a SOAP Note From a Custom Template
This page looks a lot like the one you used to create a template! It also works the same (mostly). There's some key differences you should take note of. First of all, you'll notice the large purple Use Template button at the top. This is what you'll be using to apply the template you just created.
Go ahead and click the Use Template button.
You should see this popup.
Scroll down until you see the template you just created. Click on it, and it will automatically populate the fields in your SOAP note.
You will see that the Objective section now looks like the one from your template! You will also notice that the data you entered in any of the fields will be there too.
As mentioned, this note form works exactly like the template form, so if you wanted to you could add or remove fields here as well. Let's say you didn't need symmetry on a few of your fields anymore:
You can still change the symmetry type! Pretty neat. 🤓
From here on, you can fill out the SOAP fields how you usually would for your appointments.
As an example, here is a sample appointment using the template we created earlier.
And that's it! Now you can save this note as a draft, or submit it. With the former option, you'll be able to see it on your Dashboard Inbox and get back to it at any time. The latter will save it as a completed note on the Quicknotes page (if it's a quicknote) or in the respective patient's Notebook (if it's for a patient).
Go ahead and save your note!
That's all there is to it, hope you found this tutorial helpful! As always, if there's any feedback or you would like to suggest something that might make your life a little easier, please let us know. Happy SOAPing! 😄🧼