Medical Record Form Template

Beginning with the End in Mind

The SOAPassist documentation model maximizes medical documentation through the use of templates.  SOAP notes (and almost any other kind of note) can be created on the SOAP Note Generator page by simply selecting the templates applicable to the encounter.  The data from the templates are integrated and a custom note is produced, simply and easily.  While many curated templates are instantly available to the SOAPassist user, personalized templates can also be created using the Template Creator page.  In developing the fillable form on the Template Creator page, SOAPassist began with the end in mind.  Ideally, medical documentation should be fast, accurate and complete.  Let’s talk about how SOAPassist developed the form on its Template Creator page to accomplish this.

Lightspeed Documentation

You cannot write a note any faster than having it done before you even start.  This what templates attempt to accomplish.  The problem with templates is that they are far more simple than the reality of patient care.  No two encounters are exactly alike.  Preparing templates for every scenario is impossible.  However, SOAPassist overcomes this hurdle through the use of a SOAP Note Generator.  With this tool, users select their previously entered templates and the SOAP Note Generator instantly and accurately integrates the templates, thus creating a custom SOAP note.  SOAPassist achieves this integration through the use of the Template Creator page.  This is a fillable form that contains the various components of a medical record note.  This includes not only SOAP note components, but procedure note components as well.  By entering template data into the Template Creator Page in this way, providers can instantly combine the components of the selected templates to create a SOAP note that is customized to the patient encounter.  This virtually eliminates the time spent writing or dictating and drastically reduces time spent editing.  Providers can effectively proofread their notes and then be done.

Accuracy is the Best Policy

A great concern over the use of templates is that it leaves providers prone to using boilerplate text that does not apply to the patient encounter.  The use of the template form on the Template Creator Page allows providers to be as nuanced as they would like in their templates.  Let’s take a SOAPassist curated template as an example.  Users not only have access to the “Decompensated Cirrhosis” template, but can also choose to add more nuanced templates based on the manifestation of the decompensation (encephalopathy, variceal bleed, spontaneous bacterial peritonitis etc.).  Providers can be even more detailed if they wish, having templates for various phases of workup and treatment.  The use of the template form allows for a nuanced approach to template utilization that reduces the probability of documentation error

Streamline your documentation today!

SOAPassist is the best way to create, store, share and use medical templates.

No Loose Ends

The template form in the Template Creator page does not have a character count.  Templates can be as detailed and complete as providers wish.  Feel free to name every differential diagnosis.  Leave no zebra unmentioned.  Additionally, providers can leave themselves prompts to ask important questions and consider important differential diagnoses.  This allows providers to be more complete at the initial encounter, get to the right diagnosis sooner and begin treatment more rapidly.  Each provider knows which questions they always seem to forget to ask, diagnoses they forget to consider and orders they forget to place.  Templates can minimize these occurrences leading to more complete documentation in the medical record.

SOAPassist has made a template form that is specifically designed to enable providers to achieve speed, accuracy and completeness in their documentation.  Completing the medical record can be as easy as a few clicks.  It’s time to upgrade your method of documentation.  It’s time to let SOAPassist help.

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