Summary Documentation

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 test patient, Timmy Test, via the Chart Rack.

Once the chart has opened, if the Summary is not in view, Click the Summary tab.

By default, the summary section contains:

Active Problems: The current patient problems.
Inactive Problems: Previous patient problems.
Surgeries: A list of patient surgeries.
Medications: The current patient prescriptions.
Allergies: A list of patient allergies.
Family History: The patient’s family medical history.
Tobacco: The patient’s tobacco history.
Alcohol: The patient’s alcohol history.
Interventions: The patient’s intervention history.
Social history: The patient’s social history.

(And from legacy SOAPware, but rarely used in current versions)
ROS: Review of Systems – The patient’s organ systems exam results.
Physical: The patient’s physical examination results.

Note: Discussions regarding the changing of these default Summary fields are beyond the scope of this Intro.

Active Problems

Click somewhere just below the Active Problems field header in the Summary. Type the letters AlcPro (a shortcut code for a 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 + >).
Every SMARText item can have multiple keywords/tags. These are simple strings of letters for matching during searches for SMARText documentation items. For example, prescriptions and diagnosis SMARText items in the system contain keyword/tags comprising all the words included in their names.

Now, suppose the 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 move to the next line under Active Problems, and Type dep. In order to perform a search for any existing SMARText items locally and in the online library, add the SHIFT key to the previous key commands.

Type dep and Press SHIFT + F11 or SHIFT + CTRL + > in order to obtain results similar to:

Double-click the Depression with Anxiety list item, or Click once to Select, and then Press the Enter key to insert the selected item into Active Problems.

Notice there are small up/down pointing triangles next to 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 isn't available. Red triangles should be extremely rare and usually indicate the lack of a license of some type.

When items in the online library are selected for insertion, SOAPware automatically downloads the item, adds the item to your local library, and inserts into the field.

Keyboard arrow keys can be used to move the highlight-selection up/down the list in order to select the "Depression with Anxiety" list item. Once a list item is selected-highlighted, Press the Enter key to nsert the item.

To summarize the most important issue, 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.

Quick Access key-commands:

The first ten items in the Quick Access list can be inserted by Pressing Ctrl + Shift + Number.

The second key-command , Press Ctl + Shift + Up and Down Arrow keys to move the selection of list items up/down. Once the preferred item is selected-highlighted, Press Ctl + Shift + Enter to insert it.

Congratulations!

That's it! You now have basic skills to find any SMARText item that exists in either in your local database/library or in the online, SOAPware Library. The online library contains hundreds of thousands of items including all CPT codes, ICD-9CM codes and all medications in the U.S. pharmacopeia.

Additional Summary Fields and Practice

At this point, it is wise to spend a few minutes practicing the entry of both Free Text and SMARText items into summary fields.

SOAPware Learns your Preferences

After some time and the insertion of numerous SMARText items into some of the Summary fields, go back and see how SOAPware has learned your preferred SMARText items. Click in a field and notice SOAPware Quick Access displays lists of items you have previously used. SOAPware will watch your usage and automatically rank commonly used items accordingly.

It is also important to note that not all SMARText items have shortcuts. As mentioned at the beginning, this is a code-word that when typed into a field can be 'expanded' by Pressing either the Ctrl + > or the F11 key after Typing the shortcut.

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 and simply find and insert your most common Rx, Dx, Orders, etc into the appropriate fields. SOAPware stores each users usage patterns separately so that it will learn different items for every user.

Next Steps:

    * Document Management
    * SMARText Creation
    * Docuplates
    * SMARText Sharing/Discovery
    * Pick list Customization
    * E&M Coder
    * Task Management