Documentation

The Documentation tab includes the patient’s Subjective and Objective, Assessment (SOAP) information.

To complete this information:

1. Select the Documentation tab.
   

   

2. Click to select the Assessment box.

3. Locate the Objective section, and then select Add Default. The Differential Diagnosis, Plan, and Disposition is automatically populated into the field. From here, you can make necessary edits, as needed.
   Additionally, the default may include VTEC, along with a Video to establish care checkbox. This is utilized when care is provided within a state that requires a video visit.
   

   

4. Click to select the Subjective box, and then add or edit the existing information. This information is automatically populated with the patient name, age, and chief complaint. This space is generally used to include any additional information that wasn’t included within the chat during the patient visit.
   

   

5. Select ADD if you wish to add any notes within the Administrative Notes section.