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SOAPedia Home > Introduction Guides > Introduction to SOAPware > Intro to Chart > Visit Documentation
Visit Documentation
Table of contents
- 1. Demographics
- 2. Summary Section
- 3. Summary
- 4. SOAP Encounter Notes
- 5. First SOAP Encounter Note Entry
- 5.1. View Previous Encounters
- 5.2. Subjective Entry
- 5.2.1. Chief Complaint
- 5.2.1.1. Free-Text Chief Complaint Entry
- 5.2.1.2. Structured Chief Complaint Entry
- 5.2.1.2.1. RFE = Reason For Encounter
- 5.2.2. History of Present Illness
- 5.2.1. Chief Complaint
- 6. How To Document More Than One Problem
- 6.1. Objective Entry
- 6.1.1. Vital Signs
- 6.1.2. Exam Systems Data Entry
- 6.2. Assessment Entry
- 6.3. Plan Entry
- 6.4. Medication Entry
- 6.5. Follow Up
- 6.1. Objective Entry
- 7. Remove Unused Item
Next Section: Creating Handouts
Table of Contents
- 1. Demographics
- 2. Summary Section
- 3. Summary
- 4. SOAP Encounter Notes
- 5. First SOAP Encounter Note Entry
- 5.1. View Previous Encounters
- 5.2. Subjective Entry
- 5.2.1. Chief Complaint
- 5.2.1.1. Free-Text Chief Complaint Entry
- 5.2.1.2. Structured Chief Complaint Entry
- 5.2.1.2.1. RFE = Reason For Encounter
- 5.2.2. History of Present Illness
- 5.2.1. Chief Complaint
- 6. How To Document More Than One Problem
- 6.1. Objective Entry
- 6.1.1. Vital Signs
- 6.1.2. Exam Systems Data Entry
- 6.2. Assessment Entry
- 6.3. Plan Entry
- 6.4. Medication Entry
- 6.5. Follow Up
- 6.1. Objective Entry
- 7. Remove Unused Item
Retrieve a patient chart such as the one for Timmy Test created in the previous demonstration. The work flows in this demonstration are intended to be introductions as to the processes available rather than being characteristic of actual documentation.
Demographics
Contacts/Referrals - click this link to follow path to Contacts/Referrals > Insurance Companies > Custom Demographics
Summary Section
Summary
In order to view the Summary chart section, if the Demographics section is displayed on the left, Click the Summary tab at the top left of the Chart workspace.
In order to re-display the Demographics, Click the Demographics tab (to the right of the Summary and Vital Signs tabs).
Consider practicing the entering of demographic information traveling through the various fields and noticing the various drop-down lists available for selection.
For information on Summary Documentation Click here.
SOAP Encounter Notes
On the right side of the Chart workspace, notice the SOAP Notes tab near the top left. Click the SOAP Note tab to make it active and in view. Near the bottom of the SOAP Note display, notice the empty area for the Docutainer List (If the area is not visible, click the Lower Splitter Bar). The area under the Lower Splitter Bar includes several buttons with one being to create new. To create a new SOAP Note, Click the Create docutainer button (the green plus).
Creating a new docutainer-document also automatically generates the creation of a new Tasks Manager item and displays the Add Document Task dialog. For now, just Click the Add button.
A new SOAP encounter Note format should now be displayed as in the screenshot below. This is a format created solely for training, and it will not be the format actually used for patient encounters. Later demonstrations will show how to change this default encounter format for real encounters.
SOAP Note DOCUTAINER (or DOCUment conTAINER)
This SOAP Note is not a simple document, but is a docutainer. In paper chart, an encounter note can contain multiple documents and multiple document types. A staple can conveniently associate different document types (i.e. a photo could be stapled to a SOAP Note). Staples are not available in electronic charts and the mechanisms used to associate related documents and document types are typically awkward and inefficient. In order to avoid this awkward inefficiency, docutainers were created. Docutainers are document containers in that they can contain multiple documents and multiple document types that need to be associated within any single docutainer-document. For example, a SOAP Note docutainer could contain an associated photograph. We had to come up with a slightly awkward name to differentiate docutainers (document containers) from simple documents. SOAPware is truly unique in that its docutainers can include combinations of almost any document type (i.e. Microsoft Word, PDF, videos, audio, etc.) So, a docutainer in SOAPware can offer the same capability as a staple in that it can contain and associate many documents.
To view a specific docutainer/document Click a Docutainer List Item.
Logistic Considerations for Data Entry
An important and rather unique aspect of SOAPware is the flexibility offered as to the who, when and how the actual information for documentation of patient encounters is obtained and entered. This unusual degree of flexibility allows for entry by multiple persons in differing sequences, at different locations, and at different points in time. Almost any conceivable sequence or logistics for entry of documentation is possible. This extraordinary and unmatched flexibility is only possible because of 2 decades of product evolution that has been continuously directed and blessed by busy, real world doctors.
Again, this demo of the creation of a new SOAP Note and the updating of the Summary information is for teaching-introductory purposes, and is presented in a fairly linear, simplistic fashion.
Classic and Legacy SOAP Note Fields
SOAPware derives its name from the SOAP format used for encounter documentation (i.e. S, Objective, Assessment and Plan). In SOAPware, the legacy format for encounters is for the Plan to be further divided into 3 fields, Plan, Medications and Follow-up. So, the SOAPware encounter note format could be referred to as a SOAPmf format.
- : The history or information offered by the patient.
- Objective: The findings discovered by clinical examination.
- Assessment: The diagnoses addressed during the encounter.
- Plan: The plans for the patient’s care going forward.
- Medications: The medications prescribed.
- Follow-up: The follow-up instructions.
Depending upon the size of the display and/or the amount of information in the SOAP encounter note fields, all the information within the 6 SOAPmf fields may not be able to be seen in a single view. In order to view any SOAP Note fields that are not currently displayed, Click the Up or Down Arrows in the vertical scroll bar to the far right.
Customization of the number and names of encounter note fields is deferred to other sections. We encourage all new users to initially adapt and adopt the SOAPmf format until well beyond the initial implementation phases.
First SOAP Encounter Note Entry
At this point, the SOAP Note viewer should include something similar to the screenshot below.
There are numerous starting points and ways to document encounter notes and each method has advantages and disadvantages. In this demonstration, a mouse-driven approach will be the primary method. Other methods of SOAP Note creation will be discussed in the Next Steps Guide, the Implementation Planner, and in other areas.
Many of the items used for entry of documentation are referred to as headers (e.g. the underlined, blue text items in the screenshot below) offer pick lists of items for selection. Click a header (i.e. blue, underlined text) in order to display its associated pick list items in the SMARText Quick Access dialog which, by default, is docked to the right.
View Previous Encounters
Many clinicians will want to review previous encounters during the visit and before entering documentation in the new SOAP Note.
To view previous encounters, go to the Tools menu, then click on "View Previous Encounters".
The Encounter Viewer window will pop up and you can view the past encounters by date, by Rx, or by Dx by clicking the tabs at the top of the window.
Click into one of the fields of a past encounter, and either insert the field only, or the entire encounter into the current SOAP Note by clicking one of the buttons at the bottom of the viewer window.
Subjective Entry
Chief Complaint
In the SOAP Notes docutainer, Click CHIEF COMPLAINT(S) under . Notice that an open and a close bracket appears immediately following CHIEF COMPLAINT(S). 
These brackets will define the starting and ending locations for the CHIEF COMPLAINT(S) information. The CHIEF COMPLAINT(S) header along with any information added between its brackets is all contained within itself as a discrete, object well-defined in the database. This object is also sometimes referred to as a specific type of SMARText item of the type Chief Complaint. Without becoming too technical at this point, it is important to understand that SMARText items are often pre-defined pieces of information. Additionally, they can take almost any form imaginable including simple dates, complex lists, complete prescriptions, and Order Entry items. Much more regarding SMARText item types is included elsewhere.
Free-Text Chief Complaint Entry
Documentation, in most instances, can continue to be the old-fashioned, direct entry via simple typing (i.e. Free-Text).
In order to demonstrate the addition of free-text to a Chief Complaints SMARText item, Click the CHIEF COMPLAINT(S) header, and start typing (e.g. type Hypertension).
The Item Comment dialog automatically appears and displays any/all typing. The typed, free-text appearing in the Item Comment dialog is automatically inserted inside the brackets for chief complaint by pressing the Enter key. Hypertension (as free-text) is now associated with the chief complaint, Since it is free text, it is only readable by humans having some clinical training.
In order to enter a chief complaint that can be read by humans and multiple, differing information systems, we will need to remove the free-text and enter a specific type of SMARText item.
First, to remove the free-text we typed, Click on CHIEF COMPLAINT(S) and Press the space bar (or any key), and the Item Comment dialog reappears and displays the typing. Press the Backspace key repeatedly until all the typed letters are deleted, and then Press the Enter key to re-create an empty Chief Complaints SMARText item.
Structured Chief Complaint Entry
Click on the CHIEF COMPLAINT(S), again, and notice the pick list displayed in the SMARText Quick Access dialog.
The second column in the pick list is the Description. If the Description column is not wide enough, it can be expanded. Click and Hold-down the mouse button at the right column edge of the Description column, and Drag the vertical line to the right until it is as wide as is needed. The size of the Quick Access dialog can be resized in a similar fashion.
Even if the column is not wide enough to display the Description without widening, it is not necessary to widen the column. Place the pointer/mouse cursor over any item in a narrow column, and within a second or two, a pop-up window appears displaying the complete Description. At this point, the Quick Access dialog should contain a list of system categories that organizes chief complaint items.
Click the Most Common list item's checkbox. Notice this places a check mark into the checkbox. This action also displays another list of items in the SMARText Quick Access dialog.
In this second list, Click the Description column header. Notice that this sorts the list alphabetically. Clicking again sorts, alphabetically, in the opposite direction. Click the Hypertension, Uncomplicated checkbox.
Notice the words Hypertension, uncomplicated have been inserted between/within the brackets of the CHIEF COMPLAINT(S) data entry area.
All of these lists are completely customizable. Each clinician can create their preferred lists of commonly used chief complaints. This will be covered in the Next Steps guide and elsewhere.
RFE = Reason For Encounter
Many visits don't really involve a complaint, but there is always a Reason For the Encounter, and this may or may not be a true complaint. The significance of this will also be explained later when the organization and implications of the chief complaint lists are discussed. Up to this point in this demonstration, SOAPware has been told that the primary Reason For the Encounter is Hypertension, uncomplicated. This RFE information will allow SOAPware to display more appropriate selection items in Quick Access pick lists to follow.
History of Present Illness
In this demonstration, the also contains a number of History of Present Illness SMARText items that present pick lists in the same fashion as the CHIEF COMPLAINT(S) SMARText items.
At this time, consider spending a few minutes clicking around on the HPI SMARText items and their associated pick lists. Elsewhere, the Review of Systems (or ROS) items will be introduced as well.
How To Document More Than One Problem
There is a docuplate in the online library that will allow the user to document more than one complaint.
Click the Docuplates docked tab (or Press F6).
In the Search field/box, Type starterdefault. This particular docuplate is designed to be used for 2 problems.
To add a third or fourth problem, an option would be to utilize the SMARText codes nexc, nexs or nexd. These codes will insert another, blank Subjective outline.
Next steps in Documentation are here.
Objective Entry
Vital Signs
To view the Vital Signs chart section, Click the Vital Signs tab. This tab is likely to be located on the left near the top of the Chart workspace.
Click the Add Reading Date button 
, and the appearance should be similar to the following:
Click in the Blood Pressure row under the correct date column, and Type 170, Press the Tab key, and Type 80. In order to move down to the columns below, Press the Tab key. (There is no need to enter BMI. It is entered automatically once height and weight are entered.) Below is a screenshot where data has been entered into most columns.
Once all the desired values are entered, Click the Transfer Vitals button 
. This action copies the values from the active Vital Signs column into the top of the Objective field of the SOAP encounter note as below.
Exam Systems Data Entry
Click the Exam pick list header in the Objective field. A list of exam systems will appear in the Quick Access dialog.
The default for this demonstration only displays 1 of the 14 exam systems, the GENERAL: system.
Just as in , this default template/docuplate, has a number of specific SMARText items placed into the Objective field. Clicking on their headers causes Quick Access to display pick list items. For example, Click Appearance, to display pick list items associated with Appearance.
Consider taking a few minutes, at this time, to explore the various objective exam options for inserting multiple system items, all at once.
Assessment Entry
Instead of starting with specific types of SMARText items that present pick lists in Quick Access, a different type of pick list will be demonstrated, the F11 pick list. Click in the Assessment field; Type hypert, and Press the F11 key (or Shift + F11). It is also possible to search by the ICD 9 code if it is known. This presents a pop-up pick list immediately below the typed keyword. Scroll down the list, if necessary, until the Hypertension (nonspecific) list item is visible. Double-click Hypertension (nonspecific).
The Assessment field should appear similar to the screenshot below.
Plan Entry
Click Actions in the Plan field. A list, similar to the following should be displayed in SMARText Quick Access:
Click the Lab/Tests: checkbox in Quick Access to obtain a display in Plan similar to...
Click Lab/Tests: in the Plan field to obtain a pick list similar to...
Click a checkbox in front of a list item such as LAB - Hgb A1C (Glycated Hemoglobin). This action inserts the selected pick list item into the Plan field.
For billing purposes, it is often necessary to associate a diagnosis with a lab test. In order to be able to relate the Structured Dx SMARText item types used in the Assessment field to this lab item (i.e. LAB - Hgb A1C (Glycated Hemoglobin), Click on the Related Dxs- sub-item for the lab test. This results in all diagnoses in the Assessment and Active Problems (i.e. Hypertension) to be displayed for selection in the SMARText Quick Access dialog. Select the appropriate Assessment/diagnosis item to associate it to the Plan item as below.
Medication Entry
Click in the Medicationfield; Type accu, and Press F11 (or Shift + F11). Double-click a medication list item such as Accuretic (HCTZ/Quinapril) 12.5/10mg. #30 1 qd.
This action inserts that item into the Medication field.
This demonstrates use of a SMARText item of the Structured Rx item type. It is a more complex type of SMARText item containing several sub-items and is used to prescribe a medication.
Follow Up
Notice that Return if problems worsens has been entered into the Follow up by default. However, this default can be changed and/or additional information could be typed in a free text fashion.
Remove Unused Item
SOAPware has a convenient command to clean up documentation called Remove Unused Items. This command removes any SMARText items that have not been used, and also removes extra spaces. To see this command in action, the simple route is to Press the F9 key. Alternatively, Click Edit in the menu bar; Click the Remove Unused menu item, then Click the Current Docutainer menu item. The SOAP encounter note should subsequently appear similar to the following:
That's it! You have created your first SOAP Note in SOAPware. In the next sections, we will cover basic patient Summary data entry and then move on to the End of Visit workflows.
Path- Creating Handouts
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