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Charting & SOAP Notes

The Visits tab is where clinical documentation happens. Wellgento WR supports standard SOAP (Subjective, Objective, Assessment, Plan) charting.

Starting a Note​

  1. Navigate to the Visits tab.
  2. Select the Active Visit (or create a new one).
  3. Click Add Note or select an existing note template.

The Note Editor​

The editor allows for rich text formatting and structured data entry.

  • Subjective: Patient's chief complaint and history of present illness.
  • Objective: Physical exam findings (Vitals populate automatically from the Measurements section).
  • Assessment: Diagnoses and clinical impressions.
  • Plan: Treatment steps, prescriptions, and follow-up instructions.

Auto-Save​

The system auto-saves your work periodically. A "Saved" indicator will appear in the top right of the editor.

Finalizing a Note​

Once complete, click the Sign & Lock button (if available) or simply ensure all fields are complete. Locked notes cannot be edited.