Discussion - Example of a Customized Docuplate

 Pre-Purchase --> Purchase --> Installation --> Advanced User Customization --> General Training  ---> Use/Go Live

This tutorial is intended to demonstrate some of the issues and steps related to the use of a customized docuplate. A docuplate for Upper Respiratory Infection encounters is utilized. While all clinicians may not treat this condition, we all have had at least some experience dealing with it.

This tutorial is not intended to suggest a particular type or style of documentation for URI encounters, nor is it intended to indicate what specific data elements should be used. This is just one of many ways to create documentation in SOAPware. The greatest strength and weakness of SOAPware is its degree of flexibility to adapt to almost any style.

Some practices have created customized encounter forms for use for particular types of patient visits. For example, here is an example of a very customized paper form that a practice created for their own use.

This turorial is fairly involved and extensive. To see how to just create/store a simple docuplate, see - Docuplates: Speeding up Your Documentation .

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What is particularly prudent in this form is that it allows the patient to collect most of the history in the Patient Section. The patient starts by answering the questions, and the clinician can add edits and comments while reviewing with the patient. Learning how to involve the patient, more, in the documentation process is likely to be a key to success in the future. An electronic record makes it much easier to delegate the documentation of the historical information. This is also a key means that successful practices have used to migrate to electronic records while reducing the total amount of time clinicians spend performing documentation.  Let the patient or medical assistant create the bulk of the documentation. (Actually, Instant Medical History software is often a more efficient means to collect the historical, Subjective information than what will be demonstrated here.)

Once the patient has done their part, the clinician reviews the information with the patient and makes appropriate edits. Because the intent of this tutorial is to demonstrate how to create customized workflows within SOAPware, we will assume that the clinician's assistant is usually interacting with the patient while creating the Subjective or historical portion of the encounter/SOAP note documentation within SOAPware.

This demonstration will primarily show how the elements in the above form could be incorporated into a SOAPware encounter docuplate. Having a medical assistant utilize the encounter docuplate combined with them having them update the medical summary will allow for the preferred documentation to be created very efficiently.