How do I get my patient's/client's medications into my SOAP note?

You can add a patient/client's current medication into your SOAP note's "Objective" or "Plan" section. Read on to learn how.

Objective section

1. Under the "Objective" section, click "Add Current Medications." Once you've clicked "Add Current Medications," the link will disappear for the current note (to prevent duplicates).

Note: you will want to make sure your medication list is up-to-date before doing this. You can remove active meds in E-rx>Current>Remove, next to non-active medications.

Plan section

1. Click on the "Action" drop-down below the "Plan" section, and select "Add Recent Medication Changes & Other Active Medications."  Any new e-prescriptions you've sent or discontinued within the last 24 hours will show up with "start" or "discontinue" at the beginning of each medication. If it has been more than 24 hours, active meds will show "continue" at the beginning. Once you've clicked "Add Recent Medication Changes & Other Active Medications," the link will disappear from the current note (to prevent duplicates).

Note: You will want to ensure you have sent any e-prescriptions and removed any inactive medications before doing this. 

We display recent additions or discontinuations in sentence form. For example, you'll see:

"Start Prozac 20mg tabs 1 po daily #30 RF0
Continue Klonopin 1mg tabs 1 po daily prn anxiety
Discontinue Lexapro 20mg tabs"

If you have any questions, please contact us.