SOAP Notes for YAKAP Consultations: What PhilHealth Requires

PhilHealth requires every YAKAP medical consultation — the doctor visit that follows the First Patient Encounter — to be documented as a structured SOAP note, coded to ICD-10 at Assessment, and signed off by the prescribing physician before it can be encoded, transmitted as XML, and counted toward your clinic's capitation payment.

Why SOAP Documentation Matters for YAKAP

Because the FPE is not a consultation, and PhilHealth pays and audits the two events differently. Under PhilHealth Circular No. 2025-0017, the First Patient Encounter is "the initial episode of patient contact for the year whereby a PC Clinic takes and/or updates the basic health data of an eligible beneficiary to identify their health risk" — explicitly not a medical consultation, and it can even be conducted by a barangay health worker under PhilHealth Circular No. 2024-0013. See our FPE step-by-step guide for that workflow.

The medical consultation that follows is a separate, physician-led event. Its SOAP documentation feeds the eKAS and ePresS, becomes the encrypted XML PhilHealth validates and submits, populates the four indicators behind your second-tranche payout, and is the record PhilHealth audits on a questioned claim. PC 2024-0013 is blunt about the stakes: services not reported to PhilHealth don't count toward performance.

Subjective: What PhilHealth Expects You to Capture

Record the patient's own account of why they're there — chief complaint plus history of present illness — building on, not repeating, what the FPE already gathered.

Annex G, the official Health Screening form used at FPE, already asks an 8-question review of systems, and a "Yes" to any of the eight sends the beneficiary to a doctor, per PhilHealth Circular No. 2024-0013. The consultation's Subjective section resolves that trigger into a clinical story:

Chief complaint, in the patient's words
History of present illness (onset, duration, symptoms, aggravating/relieving factors)
Relevant positives/negatives from the FPE review-of-systems questions
Smoking/alcohol and past-medical-history flags already on file — carried forward, not re-asked

Objective: What PhilHealth Expects You to Capture

Record physical exam findings and vitals, updating the FPE's baseline rather than duplicating it. Annex G already captures blood pressure, heart rate, respiratory rate, visual acuity, height, weight, BMI, temperature, pediatric anthropometrics for children 0–24 months, and blood type, per PhilHealth Circular No. 2024-0013. At the consultation, Objective should add:

Current vitals compared against the FPE baseline, with anything changed flagged
Physical examination findings by system
Diagnostic/laboratory results when available — the Konsulta/YAKAP benefit table covers 15 tests, including CBC, lipid profile, FBS, HbA1c, chest X-ray, and ECG
Red-flag findings, such as hypertensive or emergency-range blood pressure, that should escalate priority

Laboratory utilization is one of the four weighted indicators behind your second-tranche payment, so a missing lab result is a payment problem, not just a charting one.

Assessment: The ICD-10 Coding Requirement

Yes — PhilHealth explicitly requires ICD-10 coding at Assessment. PhilHealth Circular No. 2025-0013, which governs the GAMOT medicine benefit, states the prescribing physician "shall abide by International Classification of Diseases 10th Edition coding standard and shall accurately encode the appropriate diagnosis(es) for each prescription."

In practice: every diagnosis needs a valid ICD-10 code, not a free-text impression; the diagnosis must match what's dispensed, or it's a GAMOT compliance gap; and coding accuracy also feeds the antibiotics and NCD-medicine performance indicators. Free-text-only assessments that don't map to ICD-10 slow down, or block, claims processing — the XML schema PhilHealth validates against expects coded diagnoses, not prose.

Plan: Prescriptions, Referrals, and Follow-Ups

Document what happens next — medicines, referrals, follow-up — and generate the ePresS from it.

Medicines by generic name only, per the Generics Act (RA 6675), with dosage strength, form, quantity, directions, and a computer-generated Unique Prescription Security Code, under PhilHealth Circular No. 2025-0013.
Quantity limits — maintenance medications up to three months, NSAIDs up to one week, others per DOH guidelines. The pharmacy still dispenses only one month at a time on a three-month script, per the YAKAP FAQs.
Check active prescriptions first, and honor, revise, or cancel-and-reissue as needed.
Referrals for labs and cancer screening — required before a patient accesses these elsewhere, and where the eKAS diagnostics grid gets generated.
Follow-up scheduling, at the doctor's discretion based on the assessment and pending labs.

The ePresS must carry the physician's name, PRC license number, PTR number, and S2 number — pulled straight from a completed Plan.

Physician Attestation: What Encoders Can and Cannot Do

PhilHealth lets clinics delegate encoding and parts of the FPE to non-physician staff, but the clinical judgment behind a consultation — diagnosis, ICD-10 coding, prescribing — must be attested to by the physician.

FPE can be delegated to barangay health workers, RHU/BHS nurses and midwives, medical clerks, or trained allied staff, per PhilHealth Circular No. 2024-0013.
Encoding can be delegated, and PhilHealth funds it — the same circular allows capitation to pay for "non-healthcare workers such as encoders," alongside physicians, nurses, and pharmacists.
Diagnosis, coding, and prescribing cannot be delegated. PhilHealth Circular No. 2025-0013 requires the physician's own name, signature, and license number on every prescription, and ties ICD-10 accuracy to "the prescribing physician."
Identity is verified separately — every consultation runs a PCU liveness check generating a transaction number, mandatory with a signed Mutual Care Agreement on every SAP 1 submission from January 1, 2026 per PhilHealth Advisory No. 2025-0072.

An encoder can type the note, but only the doctor's credentials belong in Assessment and Plan — the attestation trail is exactly what the SOAP note and ePresS preserve.

Where SOAP Documentation Feeds Into Payment

Incomplete SOAP notes shrink your second-tranche capitation directly, because PhilHealth scores performance from what was encoded, not from what happened in the room. Per PhilHealth Circular No. 2024-0013, the second tranche (up to P1,020 of the P1,700 per-capita cap) weighs four indicators, each measured as unique beneficiaries served over registered beneficiaries with a validated FPE: consultation (30%), laboratory utilization (30%), antibiotic dispensing (10%), and NCD medicine dispensing (30%). A missing lab result or dispensed medicine means that beneficiary doesn't count — even if the service happened. See how YAKAP clinics get paid for the full mechanics.

This is also why the move off eKonsulta matters: PhilHealth is decommissioning it by July 1, 2026, with clinics already required to migrate to a certified EMR, per PhilHealth Advisory No. 2025-0077. A well-structured SOAP note only pays off if the EMR turns it into valid XML on the first try.

How RecordKo Handles This End-to-End

RecordKo's consultation form follows this exact structure — Chief Complaint and HPI, Physical Examination, an ICD-10 picker for Assessment, and Prescribed Medicines with duration-based quantity calculation for Plan — so the physician documents once and the system builds the eKAS, ePresS, and encrypted T2 XML from the same record. The PCU transaction number travels with the note, prescriptions pull the physician's name and license from clinic settings automatically, and diagnostic results and dispensing write back to the originating consultation so re-downloaded XML stays accurate. It's built for the certified-EMR era PhilHealth is moving toward, with per-section drafts so a doctor's in-progress note is never lost mid-consultation.

Book a demo ↗