SOAP Notes

Physician notes can be entered with a mix of free-text and structured responses, to fit the individual physician’s preferences and needs. Templated intake evaluations, progress notes (“SOAP” notes), treatment procedure notes, and other notes (phone interaction, medication refill request) make it easy to meet documentation expectations and requirements. Additional integral “therapy notes” can be maintained by providers while not being made available to insurers.

When detailing a patient encounter, a structured SOAP note is helpful to record what happened during the visit and what any next steps are.

• S/ Subjective narrative on interval history
• O/ Objective data from examination and lab data
• A/ Assessment
• P/ Plan

Features

Psychiatrists often evaluate patients before deciding on a course of treatment. Meeting a patient in person and hearing about their particular situation is something that BrainCloud addresses through its initial patient evaluation feature. This simple tool allows you to record the pertinent aspects of meeting a patient: who referred them, their next steps, and a rich text entry field for detailed notes.If the prospective patient elects to become a real patient and undergo either TMS or Ketamine treatments, then you can associate the initial patient evaluation note with a corresponding treatment course in BrainCloud so that it becomes part of their record.