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Summary Documentation
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There are dozens of methods and styles for creating documentation within SOAPware. In the previous demonstrations regarding the documentation of a patient encounter, a point-and-click method of data entry was primarily employed that appeals to some, but not all users. In this introduction to Summary documentation, we will demonstrate some additional methods.
Open the Timmy Test patient chart (created in previous exercise) via the Chart Rack. if the Summary is not in view, Click the Summary tab.
By default, the summary section contains:
Active Problems: Current or active problems
Inactive Problems: Previous or inactive problems
Surgeries: List of surgeries and/or procedures
Medications: Current or active medications
Allergies: List of allergies and intolerances
Family History: Family medical history
Tobacco: Past and present tobacco use history
Alcohol: Past and present alcohol use history
Interventions: Miscellaneous list of past treatments, evaluations, etc.
Social history: List social issues such as living situation, support systems, etc.
The last 2 are from legacy SOAPware, and rarely used in current versions.
ROS: Stores a review of systems of symptoms related to the various organ systems
Physical: Stores a physical examination for easy retrieval in the future.
Discussions regarding the changing of these default Summary fields are beyond the scope of this introduction.
Active Problems Entry
Entering a DX via a Shortcut
Click somewhere just below the Active Problems field header in the Summary. Type AlcPro (a shortcut code for a Structured Dx SMARText item that indicates alcohol problems), and Press the space bar. The following, or something similar should be inserted into Active Problems.
Few users prefer to memorize a bunch of shortcut code-words to enter information into documentation. Memorizing code-words was necessary to use earlier versions of SOAPware, but not anymore. To find needed SMARText items, the most common approach is now to type in a word (or part of a word, at least the first 3 letters) and press the F11 key (or use CTRL + >). For example, Type alcoho and press F11. Notice the item for Alcohol problems is in the resulting pick list, and could have been selected in this fashion. Every SMARText item can have multiple Keywords. These are simple strings of letters for matching during searches for SMARText items. For example, prescriptions and diagnosis SMARText items (i.e. Structured Rx and Structured Dx items) in the system contain Keywords comprising all the words included in their description/names.
Regarding Shortcuts:
- A SMARText item can only have one Shortcut.
- Not all SMARText items have Shortcuts.
- Users can add and change Shortcuts to meet their preferences (later).
Entering a DX via a Keyword
Now, suppose Timmy Test also reported ongoing issues with depression. In order to search/find the prebuilt SMARText items for depression, and enter one into the chart, Press Enter again to create a new line under Active Problems, and Type depre. This time, in order to perform a search both locally and in the online library, add the SHIFT key to the previous key-command (i.e. Shift + F11).
So, Type depre and Press SHIFT + F11 (or Press SHIFT + Control + >) in order to obtain a pop-up list similar to:
Notice there are small up/down pointing triangles to the left of the list items. Triangles pointing up indicate the item exists locally, and triangles pointing down indicate the item is in the online library. The triangle coloring is as follows... Green indicates the item was developed by SOAPware; Yellow indicates it is user-community created/modified; and Red indicates the item is unavailable. Red triangles should be extremely rare and usually indicate the lack of a license of some type.
in order to insert/enter the Depression with Anxiety list item into Active Problems, these options are available:
- Keyboard Method - Arrow key up or down until Depression with Anxiety is selected-highlighted, and press the Enter key.
- Mouse Method - Double-click the Depression with Anxiety list item.
- Combination Mouse/Keyboard - Click Depression with Anxiety to select-highlight, and then press the Enter key.
After performing one of the above actions, the Active Problems field should appear similar to the following:
Regarding Keywords:
- A SMARText item can have an unlimited number of Keywords.
- No SMARText item has every possible Keyword that users prefer.
- Users can add Keywords to meet their preferences.
- The longer the Keyword (i.e. typed entry to search), the faster the search.
Entering a DX from Online Library
When items in the online library are selected from the pop-up list and inserted, SOAPware automatically
- Downloads the item.
- Adds the item to your local library.
- Inserts into the field at the insertion point.
To summarize, if you do not know the exact shortcut for an item, just type in an a keyword (or the first few letters of a likely keyword), and Press either F11 or Shift + F11 to display a list that is likely to contain the desired item. This will retrieve and list any SMARText item that exists in either your local database/library or online. The online library contains hundreds of thousands of items including all CPT codes, ICD-9CM codes, and all medications in the U.S. pharmacopeia.
SOAPware Learns your Preferences
After some time, and the insertion of several SMARText items into some of the Summary fields, go back and see how SOAPware has learned your preferences. In order to see choices you have made in the past, click in a field and notice SOAPware Quick Access displays the items you have previously used. SOAPware actually counts your usage and automatically ranks the items in the list accordingly.
Train and Practice Your Summary Fields
Consider taking some time to teach SOAPware a little bit about your preferred items. The simplest way to do this is to create a practice chart, then find/insert your most commonly used items into the appropriate fields. SOAPware stores each user's usage patterns separately so that the list in Quick Access is unique to each user.
Free-text in Summary
In actual use, much of your initial data entry into Summary fields will be via clicking in the fields, and then typing the key information. At this point in 2008, there is little to be gained using structured entry in the Summary except for Active Problems, Medications, and Allergies. Even in Allergies, there will be need to add such things as food intolerances in a free-text fashion. When this is done, we suggest adding a specific SMARText item so the typed, free-text will not interfere with the drug interactions functions. That is, Type id- and Press space bar. This enters the text (ID-Ignore) at the insertion point. (ID-Ignore) will cause the sentence or line of text to be ignored in the drug interaction check.
For example, if a patient is allergic to peanuts, Go to the Summary Allergies field, Type Allergic to Peanuts; Type id-; and Press space bar to get the following:
Allergic to Peanuts. (ID-Ignore)
Also see:
Get Started with Your Own Documentation for some introductions to using pick list methods for entering Summary documentation
Next Steps:
* Document Management
* SMARText Creation
* Docuplates
* SMARText Sharing/Discovery
* Pick list Customization
* E&M Coder
* Task Management
Path - Visit Documentation
