Visits & SOAP notes
Record a visit from check-in to signed note.
On this page
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Start the visit
From the patient record, click New visit. Select the visit type (wellness, sick, surgery, etc.) and confirm the presenting complaint. The visit opens with a blank SOAP form.
Record the patient's weight at check-in — it's displayed in your clinic's configured unit and stored in kg for dosing calculations.
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Capture consent if you're recording the exam
Typing the SOAP by hand needs no separate consent step. If you use AI scribe to record the exam, click Start recording — Chartling shows the client a consent prompt first and won't start the microphone until they confirm Confirm & start recording. The consent event is timestamped and linked to the visit automatically.
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Complete the SOAP
Fill in Subjective, Objective, Assessment, and Plan. Each section supports free text plus structured fields (vitals, differentials, lab orders). Technicians can draft the SOAP before the vet arrives — the note is saved as a draft until a licensed vet signs it.
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Add medications and charges
In the Plan section, prescribe medications and add diagnostic or treatment line items. These become the basis for the invoice. See Medications & Rx for dispensing and controlled substance workflows.
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Finalize the visit
Only a licensed veterinarian can finalize a visit. Click Finalize visit to review the proposed plan items one final time, then confirm. This simultaneously signs the SOAP note, seals the visit record, and generates the invoice. Once finalized, the SOAP is locked — it can be reopened and amended, but not silently edited.
If your clinic has discharge summaries and client communications enabled, the owner is notified and can view a discharge summary in the portal after finalization.
Co-signatures
Some notes require a co-signature — for example, when a technician drafts a note that must be reviewed by a supervising vet. If a note is flagged cosign_required, the discharge summary is withheld from the owner portal until the co-sign is complete.
The supervising vet receives a task in their inbox. Open the task, review the note, and click Co-sign.
Amending a signed note
Signed notes cannot be edited in place. To correct an error, open the note and click Amend signed note. Chartling temporarily unsigns the note, records what changed for the audit trail, then re-signs it — the original signed version and the diff are both preserved.
Unsigned SOAP notes appear under Visits → Unsigned. They are not visible to the owner in the portal until signed and finalized. If a vet leaves without signing, any tech can flag the visit for follow-up.
FAQ
Yes. Technicians with the Vet Tech pack can enter vitals and add to the SOAP before the vet arrives. A licensed veterinarian finalizes the visit, which signs the SOAP and seals the record in one step. The vet can review and edit from any device before finalizing.
Chartling auto-saves the SOAP draft every few seconds. Reopen the visit from the patient record — your draft will be exactly where you left it.
No. The co-signer must be a licensed vet with an active account in your clinic. Guest or external co-signers are not supported.
Not the full SOAP — owners see a discharge summary in the portal, which is derived from the Plan section. The clinical SOAP text (Subjective, Objective, Assessment) is clinic-only.