Prepare, save, and sign an examination
SOAP sections, record state, signing, and permitted corrections.
Platform · Last verified:
SOAP brings history, observed findings, assessment, and the plan into one examination record. This guide covers the web Platform. See VetConnect for mobile usage.
Preparation
Select the correct patient/customer and check the visit date and appointment. Creation/editing requires the corresponding access. Signing additionally requires an eligible veterinarian and registered signature. Historical information is context, rather than an automatic finding of today's examination.
Create an examination
- Open New examination from patient details or the examination list.
- Check the patient, examination type, veterinarian, and visibility. For a vaccination examination, select the correct planned vaccine.
- After creation, verify the patient and state in the opened record. Reopening an existing detail does not create a new examination.
- If you came from an appointment, check its relationship. Multiple same-day appointments do not prove that a particular one was completed.
Complete the sections
| Section | Information | Check |
|---|---|---|
| S — Subjective | Owner account, reason for visit, history | Distinguish reported facts from observation |
| O — Objective | Examination findings, measurements, diagnostics | Correct date, value, and unit |
| A — Assessment | Clinical assessment and available diagnosis fields | Confirmed findings, possibilities, and ruled-out conditions differ |
| P — Plan | Planned work and clinical record links | Planned work differs from performed care |
Additional fields and visual workspaces depend on examination type. Complete fields marked required. Writing “medication administered” does not itself create an administration or stock movement. Use the appropriate operation and link the correct result.
When linking diagnostics, choose the correct confirmed result for the same patient. Removing an attachment relationship does not necessarily delete the file. Check relationships after linking plans, prescriptions, vaccines, or other records.
Watch save state
Watch Saving, Saved, Unsaved changes, and errors. Use Save when manual saving is available. If someone changed the same record, review the conflict rather than blindly saving an older screen over new work.
A Veti suggestion is draft content or a proposed operation, not proof of persistence. After application, check the canonical record. Refresh may wait while you have local edits.
Sign and verify
- Review the patient, veterinarian, sections, and linked records.
- Open Sign and close or the signing action available on your examination surface.
- Correct missing required fields. Recommended-field warnings differ from missing required information.
- Complete content review and the signing confirmation.
- Check the resulting state, signature, and preview/share options.
Assignment and signing identity can differ. A completed examination does not prove that a sale was paid or every notification was delivered.
Correct a finalized record
Signed/imported clinical content requires an explicit correction flow. If permitted, use Edit and read the reopening confirmation. Earlier revisions remain; existing share links and previous summaries may be affected. Corrected content requires a new signature.
Archiving, deleting, and reopening are different operations. Use the appropriate one. If unavailable, check record state, role, and patient access.
Example and common questions
For Kaju's visit, put the owner's appetite report in Subjective, today's measured weight in Objective, and the veterinarian's assessment in Assessment. Add planned work to Plan and separately verify actual administration records. Before signing, check that no text remains unsaved.
Why is signing unavailable? Role, veterinarian membership, registered signature, or record state may be unsuitable. See access troubleshooting.
Does a prescription prove administration? No. Prescription, administration, and stock operations are separate records. See treatment and prescriptions.
Use fields and links in detail
| Area | Recording approach |
|---|---|
| Complaint/history | Record onset/course and offered food, water, behaviour and elimination history as reported |
| Objective measurement | Date/value/unit; create or link vitals separately from free text |
| Type-specific findings | Use the selected type's form rather than substituting a general examination for every specialty |
| Assessment/diagnosis | Choose offered diagnosis/code/certainty from the clinician's assessment; primary/differential information may differ |
| Plan | Short/long plan, follow-up and owner education; link real treatment/prescription/administration through their own actions |
Creating a clinical order, adding results and linking existing diagnostics are different Objective actions. A signed record's diagnostic may be a pinned historical version; never silently substitute current content. Check charges in Sales; writing a plan does not create a sale/payment.
Linked examinations
Use the related-examination entry to create follow-up or select an eligible existing record. Verify patient and relationship direction. Read link/unlink confirmation and reopen the resulting chain. Lists may remain chronological; a badge does not regroup rows into one visit.
Customer visibility and public sharing links differ. The authorized performing clinic can change visibility; that does not reopen signed clinical content. Reopening returns to an in-progress examination; sign again and create a new share when needed.