How to Set Up SOAP Notes in Office Ally EHR 24/7
Short answer: SOAP notes live in Electronic Health Records 24/7, not Practice Mate. Templates only controls the header and letterhead across the top of your note. The screen that controls the note itself is SOAP Note Layout, where you tick the boxes for the sections you want and click Update at the bottom. Clickable phrases are built in SOAP Guidelines using Insert Link, and pulled into a chart note with Populate Guidelines.
Templates is a misnomer
You go looking for SOAP notes in Office Ally and cannot find them. Then you find the Templates area, build what you think is a SOAP template, and nothing changes except the letterhead across the top. That is not a mistake on your end. Templates and layout are two different screens, and only one of them controls what your note actually looks like.
Practice Mate and Electronic Health Records 24/7 are married. They share some information, not all of it. If you are not signed up for Electronic Health Records 24/7, you do not see these screens at all.
The steps
Log in. You land in Practice Mate by default. Move to Electronic Health Records 24/7, because SOAP notes are only available there.
Go to Templates. This is not a SOAP note structure builder. It controls what shows up across the top of your note, essentially your letterhead.
The editor behaves like a word processing document. Enter your practice name, address, and other header information. A logo can be uploaded and inserted.
Name and save the template, for example PT Daily Documentation.
Do not try to build subjective, objective, assessment, and plan here. That structure is not configurable on this screen.
Go to SOAP Note Layout. This is the screen that controls what your note actually contains. There is a default layout called Daily Documentation.
Tick the boxes for the sections you want to appear. Anything checked shows up on the note and becomes fillable.
On the subjective side, chief complaint and subjective.
On the objective side, vitals, physical exam, expansion, plus any custom areas you name. Examples in use include therapeutic exercise, physical agents, manual therapy, and neuromuscular re education.
On the assessment side, tick SNOMED if your practice uses SNOMED codes.
Tick phrase list and then edit the phrase list if you want stored phrases for a specific section. A phrase list is not the same thing as a guideline. It belongs to the section it is attached to.
Add care plan and goals, and patient instructions, if you want them on the note.
Scroll to the bottom and click Update.
Go to SOAP Guidelines. These are the clickable phrases that populate the note. Guidelines need actual code around the text to become clickable, and the system builds it for you through Insert Link.
Type the phrase you want, for example, on a scale of one to ten.
Click Insert Link. The prompt asks you to drag the mouse to highlight the block of text or phrase.
Highlight the phrase, then click the insert link button again. The code wraps around the phrase and it becomes clickable.
For long lists, type all your phrases in a Word document or Google Doc first, paste them in, then insert the links one by one.
Populate any section you want guidelines to appear in, for example objective findings.
Open a patient chart note. Guidelines are marked with a G.
Click Populate Guidelines at the top of the note to pull your guidelines in.
Check the result. Populate Guidelines pulls from the layout you are working in, so if you built guidelines under one layout and are documenting in another, they will not all appear. Confirm you are in the right layout.
Click each guideline to enter it into the note. On a touch screen you can tap them, and a stylus works too, which removes almost all the typing.
Fill the small blanks you left, such as number of minutes, time in, and time out.
Work through the sections: time in, current symptoms, pain scale, minutes, physical agents such as ultrasound, manual therapy, and soft tissue.
To add a new guideline, know the limit first. A new guideline cannot be created from the assessment section.
From the objective section, click the G and choose New Guideline.
Type the phrase, and leave the ending open if you want it to work for more than one body area. Click Add. The guideline is saved and appears every time going forward.
Choose your therapy codes and your modifiers. For physical medicine that is often GP, though not every insurance company requires it. Click Update.
When the patient returns, open their chart and click Copy to New Note. Everything from the last visit carries forward: time in, symptoms, pain scale, minutes, diagnosis code, and procedure.
Use it as a review. Seeing what the pain scale was last visit against what it is today is the comparison the note is supposed to show.
Adjust only what changed, such as minutes of therapeutic exercise or manual therapy, and update the goals if they have changed.
Set time out at the bottom. Military time is an option if you prefer it.
Choose the plan, enter any patient instructions, and click Update. The new note is complete.
If the account is set up properly and the insurance and billing information are entered, click Create Visit directly from the note. You do not have to create the visit when the patient walks through the door.
Go back to Practice Mate and pull up the visits. Before billing, check each visit for edits. A Medicare claim may need the correct NPI so it bills properly.
Tick the box next to the visit you want and choose Create CMS 1500. This is the current name for the form formerly called the HCFA.
From here you can print the claim, click Submit on the individual claim, or tick the check mark and choose Submit Claims to send a batch.
Why these are three separate jobs
Templates sets the letterhead. SOAP Note Layout decides which sections exist. SOAP Guidelines supplies the clickable phrases that go inside sections that already exist. Treat them as three separate jobs and each one takes minutes. Treat them as one and you will spend an afternoon in the wrong screen. Most software frustration is not a skill problem, it is a naming problem.
The mistake this prevents
Trying to build the SOAP note in Templates. It is named as though it controls the note, and it does not. Practitioners lose real hours in that screen trying to construct subjective, objective, assessment, and plan, and come away convinced the software cannot do what they need. The setup work never gets done, so the practitioner types every note from scratch forever, which is the exact cost the system was supposed to remove. The second trap is sequence. Populate Guidelines pulls from the layout you are currently in, so guidelines built under one layout will not fully appear when you are documenting under a different one. If the button seems to only half work, check which layout is open before assuming the guidelines are broken. And a new guideline cannot be created from the assessment section. It has to be created from the objective section, where the G is available, and once it is added there it is available everywhere afterward.
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Marie Matteson, MS, is a healthcare consultant, educator, and Office Ally specialist with more than 30 years in healthcare, emergency medicine, and practice management. Helping you understand what's really going on.
All patient information referenced here has been redacted. This content is educational and is not billing, legal, or coding advice. Always follow your payer contracts, your practice policies, and current coding guidelines. Not affiliated with or endorsed by Office Ally.
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