# SOAP tabs

The **Diagnosis** tab in the **Medical Records** screen includes various SOAP tabs in the middle panel for data entry.

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## Various SOAP Tabs

### **Patient Vitals**

Includes fields for entering vital details. Click the **Expand** arrow to open the section.

<figure><img src="/files/63C342TszJeRVBktAvLL" alt=""><figcaption></figcaption></figure>

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### **Allergy**

This tab is **locked** for editing and displays any existing allergies. To add or update allergy details, go to the **More Actions** section in the right panel and select the **Allergy** icon. For detailed steps, refer to the [**Patient Allergy**](/uniteemr/application-modules/medical-records/more-action/patient-allergy.md) topic.

<figure><img src="/files/1J6U0eUaxyuQD2eFIzrR" alt=""><figcaption></figcaption></figure>

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### **Nurse Notes and Doctor Notes**

The **Nurse Notes** SOAP tab is locked for non-nurse users, as this section is reserved for nurses to enter notes. Similarly, the **Doctor Notes** SOAP tab is locked for non-doctor users, as it is reserved for doctors to enter notes. Both the **Nurse Notes** and **Doctor Notes** SOAP tabs are text fields for data entry.

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### **Additional Text Fields**

**Complaints**, **Observations/Physical Examination**, and **Notes** are text fields for entering additional clinical details.

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### **Diagnosis**

#### Selecting ICD Codes

ICD (International Classification of Diseases) codes can be added from the **ICD Master List** within the Diagnosis tab.

* Hover over the **Diagnosis tab** to display the **ICD** and **Template** buttons. Click **ICD** to open the **ICD Master List** pop-up.

  <figure><img src="/files/CwJWt0m4L6hIL09Qutg5" alt=""><figcaption></figcaption></figure>
* Use the **Search field** to find ICD codes by code or description. Relevant codes are listed in a grid format. Select an ICD code to add it to the SOAP tab; multiple selections are allowed.

  <figure><img src="/files/0QbB2P97Ebm4E1vRD4yC" alt=""><figcaption></figcaption></figure>
* Click the **Favorites icon** to add an ICD code to your **Favorites list**.
* Use the Filter dropdown to refine your view by selecting one of the following options:

  * **Show All**: Displays all ICD codes based on your search.
  * **Show Selected**: Shows only the ICD codes you have selected.
  * **Show Favorites**: Displays only the ICD codes saved in Favorites.

  <figure><img src="/files/5Zi2WTcDFxtsU3Gppq07" alt=""><figcaption></figcaption></figure>
* Click **ADD** to include selected codes in the SOAP tab. The first selected code is marked as primary, indicated by <mark style="color:red;">(P)</mark>.

  <figure><img src="/files/pm8ge0ZnAqk3FFMm1dvO" alt=""><figcaption></figcaption></figure>

**Add New ICD**

If the required ICD is not available in the **ICD Master List** pop‑up, a new ICD record can be created.

<figure><img src="/files/oOI0KlZIElLsMhgERE9Y" alt=""><figcaption></figcaption></figure>

* Click **ADD NEW ICD** to create a new ICD record. This action opens a pop-up to capture the new ICD details.
* Enter the **ICD Code** in the specified format and provide the **Description**, then **SAVE** the record.
* Once saved, the newly added ICD becomes available in the **ICD Master List**.

**Changing Primary Diagnosis**

* Click **REMARKS** on the Diagnosis SOAP tab to open the **Diagnosis Remarks** pop-up.
* In the **Is Primary** column, select the desired ICD to mark as primary.
* Click **ADD** to save the change.

  <figure><img src="/files/JtLvHroBaz07LMDxKlVv" alt=""><figcaption></figcaption></figure>

**Unselecting ICD Codes**

* Hover over an ICD in the Diagnosis SOAP tab to reveal the **Delete** button, then click **Delete** to remove the ICD from the tab.

  <figure><img src="/files/qM0A2j1bk5qJDSPPiYPC" alt=""><figcaption></figcaption></figure>

**Direct ICD Search from SOAP Tab**

* You can also search ICD codes directly from the SOAP tab.

  <figure><img src="/files/wsgtq32gIth29fbxULIe" alt=""><figcaption></figcaption></figure>

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### **Additional SOAP Tabs**

The Diagnosis tab includes additional SOAP tabs for documenting specific details, with each tab displaying items from its respective item type: **Procedure**, **Investigations**, **Services**, **Radiology**, **Drugs**, **Consumables**, **Dental Procedures**, and **Packages**.

Each tab allows item selection from the **Individual Price Card**. For more information, refer to the[ **Individual Price Card** ](/uniteemr/application-modules/medical-records/diagnosis/individual-pricecards-and-templates.md)section.

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### **Confidential Notes**

The **Confidential Notes** tab is mainly for psychologists. Data entered here is confidential and accessible only to the user who added it.

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### **Dental Procedures**

The **Dental Procedures** tab is primarily used by dental practitioners. The treatments marked as **Move to billing** in the [**Dental Chart**](/uniteemr/application-modules/medical-records/dental-chart.md) tab will be reflected in the Dental Procedures SOAP tab.

To add treatments in the **Dental Procedures** SOAP tab:

* Select **PRICE CARD** in the SOAP tab to access a list of treatments.

  <figure><img src="/files/23iOdIg3SqzJjj5WFl7b" alt=""><figcaption></figcaption></figure>
* Select and **ADD** the treatment to the SOAP tab.
* After a treatment is added, the **REMARKS** button is also available in the SOAP tab. Hover over the SOAP tab and select **REMARKS** to open the **Dental Procedures Remarks** pop-up, where you can:
  * Update the **Quantity** of the treatment.
  * Check **Cosmetic in nature** to apply VAT if applicable.
  * Add remarks in the **Remarks** text field if needed.
  * Update the **Tooth Number** field based on the patient's dental type (Adult or Primary).\
    \&#xNAN;***Note:** If the configuration is enabled, additional fields such as **Start Date & Time** and **End Date & Time** appear in the pop-up for capturing details.*

    <figure><img src="/files/R1YTEhvnq5UXJjS8MvFW" alt=""><figcaption></figcaption></figure>
* Any updates will be reflected in the Dental Procedures SOAP tab and respective invoice.

  <figure><img src="/files/TawOcKNoP8KWBRlk3w4h" alt=""><figcaption></figcaption></figure>

***

### **Billing Advice**

The **Billing Advice** tab is a text field where doctors can enter information for the front desk.

* Medical professionals can enter relevant information in this tab.

  <figure><img src="/files/W8Thr0nl6lcdsctH5k5Y" alt=""><figcaption></figcaption></figure>
* When the billing staff opens the invoice, the entered information is fetched and displayed in the [**Doctor’s Bill Advice**](/uniteemr/application-modules/billing/invoice/invoice-sections/patient-invoice-s.md#doctors-bill-advice) field.

  <figure><img src="/files/CWQ3lFacjalsusOWjBAq" alt=""><figcaption></figcaption></figure>

{% hint style="info" %}
SOAP tab availability may vary based on clinic configurations. Specific tabs may be enabled or disabled according to clinic requirements.
{% endhint %}

***


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