Treatment & Progress (SOAP) Notes

Implementation Date: 1/21/2010

Date of Last Revision: 1/21/2011

Next Review Due: 4/2023

 

Reviewed by VTH Administrative Team: 10/20/2009

Reviewed by VTH Board: 11/19/2009; 1/21/2010; 1/21/2011

 

Reviewed by Legal Counsel: N/A

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Administrative Team without approval.

Policy

As part of the Problem Oriented Veterinary Medical Record, Treatment and Progress (SOAP) notes are used to document subjective, objective, assessment and plan of care information for patients

Guidelines

Treatment and Progress (SOAP) Notes are documented in the electronic Medical Record and e-signed as soon as possible.

A veterinary technician or veterinarian may compose and e-sign their own note.

Veterinary students shall save the notes which are e-signed by a clinician as soon as possible.

Procedure (if applicable)

“Date” on the Treatment and Progress (SOAP) is the date the exam/procedure is performed rather than the entry date.

Before the Treatment and Progress (SOAP) notes are e-signed, they may still be edited. 

These notes will no longer be printed and signed for inclusion in the paper record. However, notes may be printed by the students for review with the supervising clinician and any necessary corrections made in the electronic document prior to it being e-signed.

Once e-signed, they may only be updated by adding an addendum, which does not change the original entry. To correct an error in notes that have been e-signed, they must be retracted and re-entered. Retracting the notes removes them from public view while maintaining an unobliterated document that may be accessed by Administrators. 
To have notes retracted, send an email to Medical Records at medrec@cvm.uiuc.edu (include the specific reason for retracting the notes for auditing purposes).

Audits on Treatment and Progress (SOAP) notes will periodically be conducted.

Notes not e-signed within 96 hours, by default setting in the hospital information system, will be locked and no longer editable. 

Definitions (if applicable)

Locked: Reports by default setting within the hospital information system may be set to be locked within a given number of days. Once the report is locked it is no longer editable. An addendum may be added to the report, or the report may be retracted from view and rewritten

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.