II. Data Entry

1. Issues to address
2. Patient History
3. Other Specifics to Plan For

Table of Contents

1. Issues to address
2. Patient History
3. Other Specifics to Plan For

Most sites using SOAPware do sometimes include handwritten documents and dictated-transcribed documents at times (or for a few of the clinicians).

Handwritten charting as the primary data entry method is quickly becoming obsolete. If the clinician is writing notes, then it is impossible to be able to find and report the required data in order to get full payment for services. It certainly is unlikely the documentation will even stand up to review by outside parties. Even if written notes are complete enough to survive manual reviews, then way too much valuable clinician time has been spent writing. Once created, there is no easy way to retrieve the information in written or dictated records. Whether written or dictated, most clinicians are creating redundant information and usually do not go to the trouble to document the pertinent negatives or the true extent of the evaluation and treatment plan. Often, the later tends to seem redundant or obvious to clinicians. However, to any outside party, if it was not entered into the chart then it was not addressed.

Free dictation is inefficient, expensive and is unable to create data that can be searched, retrieved, and reported.

With SOAPware, many types of protocols or guidelines can be implemented. Learning how to use the various tools (i.e. docuplates(templates, tasks manager, etc) allows the introduction of more consistency and diligence in automatic fashions. Also, they often allow for others to relieve the burdens on the clinicians by allowing for much of the clerical work within documentation to be delegated to others. This frees the clinician to be more focused on the patient and is just one of the means for working smarter, rather than harder.

Issues to address

Episodes, Problem Management - Problem Oriented Care
- Manage clinical documents and notes
- Care Management
Lookup of patient
Patient Demographics
Patient and family preferences

Patient History

Chart summaries
Problem Lists
Medication List (Current and Historical)
Allergy List
Vital signs
Patient entered data

It is recommended that the clinician's nurse or assistant take the patient history. This leaves the clinician able to verify and edit the information when examing the patient instead of playing "20 questions". On average this cuts 6 minutes off of each visit time for the clinician, which allows for seeing more patients during clinic hours. Another benefit of delegating these items to properly trained employees is that the clinician is not doing the bulk of clerical data entry and the enounter is finished when the clincian leaves the room, thus eliminating after hours and weekend "catch up" charting.

Other Specifics to Plan For

Capture of clinical findings, documents, etc. through various means -- narrative, docuplates, structured documents, data sets, and coded data.
Medications, medication management (includes prescriptions.
- Drug alerts.
Decision Support
Health Maintenance, Preventive Care, Wellness, Disease Management
Clinical Pathways and reminders
Chronic disease management, Disease based protocols
Disease Registries
Rule-based alerts and/or clinical reminders
Patient Flags, Precautions, and Adverse Events
Care Planning, Critical Paths, Protocols, Interactive care plans
Passive guidelines for clinical support during data entry/patient care
Diagnostic decision support
- Access to knowledge sources
Enable business/regulatory rules and guidelines
Operations Management and Communications
Operations Work Flow (including staging, sequencing, and routing)
Scheduling
Work Lists (Task or "To-Do" items)
Orders/Referrals
Results Management
Document disposition/routing
Orders - Patient advice and instructions.
Communication
- Inter-Practitioner Communication
Team Coordination
Practitioner/Patient/Family Communication
Patient, Family and Care Giver Education
Logistics and Room Management
- Patient Locator
- Practitioner Locator
Consents and Authorizations