Taking notes in SeriousMD allows you to keep detailed, organized records of each patient interaction, all within one platform. Here’s a step-by-step guide to get started with notes, especially SOAP notes, and make the most of the available tools.
Watch Video Guide
Step 1: Open a Patient Record
If you haven’t created a patient record for this person yet:
Go to Patient Records and click on New Patient. Fill out the patient’s details and save the record.
Step 2: Click the “+” Icon to Add a Note
Once in the patient’s record, click the + icon to bring up the note-taking options.
Step 3: Choose SOAP Note
When you select the SOAP note, you’ll see the standard SOAP sections
The left panel provides various additional forms that you can attach to the SOAP note for more specific information.
These forms act like separate sheets, allowing you to keep detailed records for areas such as:
Allergies
Immunization History (ideal for Pediatricians tracking their patient's vaccine history)
Growth Milestones (also for Pedias)
Obstetric History (ideal for OBs tracking past and current pregnancies)
Family History, among others.
Step 4: Attach Additional Notes, Images, or Files
You can upload images or files, with a maximum size of 25MB per file, to further supplement your notes.
There’s also a drawing tool, allowing you to use image templates or freestyle with your annotations.
Step 5: Add Lab Requests and Monitor Vitals
Upload and view lab results and track vitals over time. Tracking vitals helps you monitor trends and maintain a holistic view of the patient’s health.
Uploading Lab Results
Adding Patient's Vitals
⏲️ Note: Uploading Vitals and Lab Results (Optional for Secretaries/Nurses)
Your secretary or nurse can upload Vitals and Lab Results in advance. This information will then be ready for you when you start your consultation.
To enable this, you can add your secretary as a sub-user with limited access. By default, sub-users can upload Vitals and Labs but cannot access your notes, ensuring privacy.
With Vitals and Labs already included in the encounter, you’ll have these details ready for review during the appointment.
Step 6: Create Your Prescription/Lab Request/Medical Certificate
You may find the Prescription, Test Request and Certificate form in the left panel.
Step 7: Saving and Organizing Your Notes
After completing your notes, click to save them. Each note will be attached to the SOAP note and organized under the appropriate tabs in the patient’s profile (e.g., History, Labs, Vitals).
Bonus Feature: Access Custom Forms for Your Practice
SeriousMD also offers a library of custom forms tailored to various specialties. You can explore the library to find forms relevant to your practice.
Go to Settings > Templates > Custom Form
Click on Library and search for the custom form then click Download
If you need a specific form not available, simply reach out to our support team, and we can help create and import it directly into your account.