Visits & SOAP notes

Clinic staff Vet signature required to finalize

Record a visit from check-in to signed note.

app.chartling.io C Chartling GETTING STARTED Quick start PATIENTS & CLIENTS Patients Clients CLINICAL Visits & SOAP AI scribe Medications & Rx Controlled subs. Lab orders Discharge & comms AI FEATURES Clinic Copilot Clinical support SCHEDULING Appointments BILLING Invoicing & pmts SERVICE MODULES Boarding Daycare Grooming Training TEAM & SETTINGS Team & permissions Clinic settings SMS & reminders Audit log Docs › Chartling › Visits & SOAP Visits & SOAP Luna Rodriguez · Wellness exam · Jun 23, 2026 AI Scribe S Subjective Owner reports decreased appetite for 3 days. Lethargy noted. Vomiting once yesterday... O Objective T: 39.2°C · HR: 88 bpm · RR: 24 · Wt: 32.1 kg · BCS: 5/9 A Assessment Gastroenteritis, likely dietary. R/O foreign body, pancreatitis. P Plan Bland diet × 3 days · Metronidazole 250 mg PO BID × 5 days · Recheck if not improving Sign & finalize

On this page

  1. 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.

  2. Consent is always on record

    Every SOAP note needs a linked consent event before it can be saved. Chartling enforces this server-side, so there's no way around it. Typing the SOAP by hand doesn't prompt the client; Chartling logs a one-party consent event automatically on your behalf (no audio, just your own typed notes). 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. Either way, the consent event is timestamped and linked to the visit automatically.

  3. 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.

  4. 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.

  5. Sign and finalize the visit

    Finalizing requires the visit.sign permission (Vets by default). Click Sign & finalize visit to review the proposed SOAP, medications, and charges one final time, then confirm. This signs the SOAP note (status moves to signed, with a signer stamp and timestamp, never a draft), seals the visit record, logs any controlled-substance dispenses pending witness, and posts the medication and inventory movements. Once finalized, the SOAP is locked. It can be reopened and amended, but not silently edited.

    Invoicing, reminders, and the owner discharge email/SMS only fire for clinics whose plan includes them (Practice includes all three; Intelligence generates the discharge content but not the invoice, reminder, or send. See Discharge & comms). A cosign-required note is signed and sealed immediately, but its owner-facing discharge is held back until the supervising vet co-signs.

Invoice generation depends on your tier

The signed SOAP, medications, controlled-substance logs, inventory movements, and visit seal always happen on finalize, on every tier. Generating the invoice is a separate, gated step available on Operations and Practice. An Intelligence-only clinic gets a signed, sealed visit with no invoice, since Intelligence orgs typically bill through an external PIMS. See Invoicing & payments for which tiers include invoicing.

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 visits

Unsigned SOAP notes appear under Visits → Unsigned, scoped to your own notes. They are not visible to the owner in the portal until signed and finalized. From that tab you can select several ready notes and batch sign them in one action instead of opening each visit individually, which clears end-of-day note debt quickly.

FAQ

Can a technician start the SOAP before the vet arrives?

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.

What happens if I close the browser mid-visit?

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.

Can a note be co-signed by someone outside the clinic?

No. The co-signer must be a licensed vet with an active account in your clinic. Guest or external co-signers are not supported.

Does the owner get a copy of the SOAP?

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.

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