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SOAPedia > Introduction Guides > Next Steps > Documentation of Visit - Next Steps > Objective Documentation
Objective Documentation
Table of Contents
There are multiple means to insert whole blocks of Objective/exam documentation items. For example:
- Insert from the Objective menu.
- Enter a SMARText item.
- Enter a docuplate that inserts items.
Insert from the Objective Menu
In order to populate the exam with documentation using a menu options, Right-click Objective, and Click Insert Exam Headers.
The results are for the headers to be inserted in the Objective field.
Exam Headers
The Insert Exam Headers option in the Objective menu is the simplest option. This Inserts headers and items that will result in a starting point very similar to the example above. Finally, the Insert Normal Exam inserts a starting point that is more completed.
Note: If the inserted items differ much from these examples, then you probably want to perform an update of the SMARText items.
Start the Exam Documentation with a SMARText Item
Insert SMARText Item - ObjX
Most clinicians will want to pre-build their exams and use them to create encounter documentation (and docuplates). Below is an exam of a pre-built exam that has default/normal information for the General Medical Exam as defined by CMS.
Insert SMARText Item - ObjN
Insert Docuplate - ObjHa - (Objective Headers - All)
CMS has defined several other types of exams in addition to the above General Medical. Below are all the Objective exam headers that have been defined in all types of exams (according to CMS/AMA).
Also see the examples in the Tutorial - Create and use a customized docuplate and Objective workflow demo for URI .
At this point in time (April, 2009), the SMARText framework as illustrated above (i.e. the blue headers) is the extent to which formal, specifcs have been created within SOAPware (and defined by CMS/AMA). There is still much work remaining to define the specific findings (i.e. the black text entered after the blue headers). Therefore, for the immediate future, there is little to be lost to enter the specific information after the blue headers in a free-text typing fashion. Simply click on one of the blue headers and start typing.
Vital Signs Are Transferred
Note that the vital sign information is transferred into the Objective field to complete the documentation. If the starting point is to use a menu option to enter objective information, the transfer needs to be afterward. Using the SMARText or docuplate starters, the transfer can be before or afterward.
