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Provider and Technician Quick Start Guide

Table of Contents

How to Create SOAP Notes                     3

Accessing a Created SOAP Note             5

SOAP Entry                                              7

Lab Orders & Results                             11

Client Communications                          13

Prescriptions                                          16

NaVetor Support                                    18

How to Create SOAP Notes

There are a few different ways SOAP Notes are created.

Through a checked-in appointment 

o   When an appointment or reservation is checked in or admitted it will automatically generate a SOAP Note.

Search bar > Notes 

o   When searching for a patient or client in the search bar it will display a quick-access button with a + to the right of the Notes button on the right. 

Patent Dashboard 

o   When on the patient dashboard go to the Notes tab on the left, then select the Add Encounter icon on the top. Then you will need to select Phone, Email, or Fax and hit Save. However, if you check the box that says Note it will NOT create a full SOAP it will only create a Simple Note with an open text format. 

How to Create SOAP Notes (cont.)

Search bar > Notes When searching for a patient or client in the search bar it will display a quick access button for Notes. Selecting this button will allow you to view all of the Encounters for this specific patient, then select the Add Encounter icon on the top.   Then you will need to select Phone, Email, or Fax and hit Save. However, if you check the box that says Note it will NOT create a full SOAP it will only create a Simple Note with an open text format.

Accessing a Created SOAP Note

How to access a SOAP Note

Through a checked-in appointment 

o   When accessing an encounter from a checked-in appointment you will start from the scheduler and single-left-click anywhere on the checked-in appointment. It will give you several drop-down options, simply select SOAP Note.  

Paw Print AND Recent SOAP

o   By selecting the Paw Print in the top right, it will allow you to see the last six patient records that you accessed, by simply clicking Recent SOAP it will allow you to quickly access the most recent SOAP for that patient. 

Search bar > Notes 

o   When searching for a patient or client in the search bar it will display a quick access button for Notes. By selecting this button, it will allow you to view all of the Encounters for this specific patient. 

Accessing a Created SOAP Note (cont.)

Patent Dashboard 

o   When you are in a specific patient dashboard it will allow you to see and view a list of all encounters by selecting the Notes tab on the lower left. From within this tab if you need to access a specific SOAP select the Go to SOAP button. Also, if you are in the invoices tab on the patient dashboard it will allow you to access the SOAP associated with a specific invoice, just simply select Go To SOAP from this screen.

Medical Records > Clinical 

o   When a patient is already displayed in the banner, and you go to the Navigation Menu > Medical Records > Clinical it will take you directly to a list of all of the specific patient's encounters. 

SOAP Entry

Subjective

o   The visit reason(s) added to the appointment will be displayed here and it will allow you to add additional information. You may also use the + Add button to add a Past History Template.  

The SOAP Note Keeps track of your important data with our comprehensive SOAP entry process.

 

The user can toggle between patients for multi-patient appointments. Note: Always save changes before moving to a new patient. 

SOAP Entry (cont.)

Objective 

o   This is the area where you will add any Vitals, General Templates, and Physical Exam EMR templates or System Exams. 

SOAP Entry (cont.)

Plan 

o   This is where you add prescriptions, vaccinations, lab orders, procedures, and inventory. All billable items added to the Plan will show on the invoice and items added to the invoice will show here in the Plan.  All items can be added by type, or you may also use the + Bundle or + Add Item options. 

o   You may also add recall reminders, decline items, add attachments, create future appointments, and client communications within the Plan. 

Assessment 

o   In this area, add new problems, enter the diagnosis, and add a General Assessment. 

SOAP Entry (cont.)

You may also use the tabs on the right margin to access previous SOAP Notes, Invoices, and Problems. 

Use the buttons to sign the completed SOAP, assign the SOAP, create an estimate, and print. 

Lab Orders & Results

For example, if you are running an in-house CBC through your VetLab Station you would select Idexx and then you will see the option for in-house, you would NOT select In-House as your Lab company.

Lab Orders & Results

Whether you are using a lab integration or just manually adding your labs it is best to create your lab orders through the Plan in the SOAP Note. You will want to use the + Add button next to the Lab Orders & Results. 

From the Create Order screen, you will need to pick the correct Lab company. 

NOTE: If you are using any lab integration and the result for this test is being loaded through that integration you must select the integrated lab company (Idexx, Antech, or Zoetis) AND the order must be placed before the result is ready. The company listed as In-House is used when you are manually typing in the results or manually uploading a result. 

Lab Orders & Results (cont.)

If you are using a lab integration, the results will automatically be uploaded in the SOAP Note, Lab Worklist, and on the Patient Dashboard. If you are manually adding an attachment or using a Lab Result Template, this can be done in the SOAP Note or the Lab Worklist. 

To access the Lab Worklist, hover over the navigation menu > Medical Records > click on Lab Worklist. 

To upload an attachment or use a Lab Result Template, select the upload icon in the action column. From here you may use the Select files to manually attach a result or you may select one of the Lab Result Templates.  

Client Communications

When logging a communication with the client you will need to decide if this is something you wish to just have noted on the client account or if this is something that you want to be a part of the patient's medical record. 

If you wish to make a note on a client account that is NOT a part of the patient's medical record this can be done from the Client Dashboard and the Client Communications tab. This is where you may want to make notes regarding billing agreements, sending to collections, or anything that is not relevant to the patient medically. Simply select Add on the top. 

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Client Communications (cont.)

If you wish to make a note that will show as part of the patient history, this can be done from the Patient Dashboard or the Encounters screen. 

Patent Dashboard 

o   When on the patient dashboard go to the Notes tab on the left, then select the Add Encounter icon on the top.  Then you will need to select Phone, Email, or Fax and you MUST check the box for Note before hitting Save. This will create a Simple Note with an open-text format. If you do not check the box it will create a full SOAP. 

Client Communications (cont.)

Search bar > Notes When searching for a patient or client in the search bar it will display a quick access button for Notes. By selecting this button, it will allow you to view all of the Encounters for this specific patient, this will give you the option to create a new Encounter or you may also add a Note to an existing Encounter. To create a new Encounter select the Add Encounter icon on the top right. Then you will need to select Phone, Email, or Fax and you MUST check the box for Note before hitting Save. This will create a Simple Note with an open-text format. If you do not check the box it will create a full SOAP.
If you want to add a Note to an existing Encounter to the right of that encounter you will want to select the Add Document option and choose Note. This will create a Simple Note with an open-text format

Prescriptions

When prescribing a medication, whether it is something new for the patient or if it just has never been invoiced through NaVetor, you will need to add this medication to the Plan of a SOAP Note or add it directly to the Invoice. 

Adding Prescriptions to the SOAPWithin the SOAP Note you may add your prescriptions by simply going to the Plan section and selecting Add Prescription. From here you can search for medications, add multiple medications, adjust the quantity, add refills, and add/edit dosage instructions. Once the prescription(s) have been saved you may print a label by selecting the printer icon in the action column. 

Prescriptions (cont.)

Adding Prescription to the InvoiceWithin the Invoice select the Add Item option search and select all items needing invoicing before selecting Back. Once the item(s) are on the invoice you may adjust the quantity being given, you may also add No of Refills available and the Quantity Per Refill. (Note: if you do not see the option for refills expand the item using the arrow on the left.) Once the invoice has been saved you may print the prescription label(s) using the Print Label option on the bottom of the invoice. 

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