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SOAPedia Home > Implementation Guides > 4. Customization Optimization > Pay for Performance (P4P) Initiatives > Documentation Items for Reporting
Documentation Items for Reporting
Table of contents
- 1. Important Date-Related Sub-items to Activate
- 2. Encounter SOAP Notes
- 2.1. Objective Field
- 2.1.1. Vital Signs
- 2.1.1.1. Blood Pressure
- 2.1.1.2. Height
- 2.1.1.3. Weight
- 2.1.1. Vital Signs
- 2.2. Assessment Field
- 2.3. Plan Field
- 2.3.1. Procedures
- 2.3.2. Vaccines - Adult
- 2.3.3. Vaccines - Pediatric
- 2.3.4. Lab Tests and Other Studies
- 2.3.5. Referrals
- 2.1. Objective Field
- 3. Summary - (Past Medical History Issues)
- 3.1. Active and Inactive Problems
- 3.2. Surgical History
- 3.3. Medications
- 3.4. Allergies
- 3.5. Family History
- 3.6. Tobacco Issues
- 3.7. Social History
- 3.7.1. Advance Directives
- 4. Demographics
- 4.1. Age
- 4.2. Gender
- 4.3. Race or Ethnicity
- 5. Administrative
- 5.1. Appointments**
- 5.1.1. Last visit
- 5.1.2. Next visit
- 5.1.3. Last Comprehensive Exam visit
- 5.1.4. Next Comprehensive Exam visit
- 5.2. Refuse/Decline Any/All Procedures
- 5.1. Appointments**
Table of Contents
Once the specific data elements to be reported are known, the following information gives guidance as to how to caputre the data elements to be reported. In order to understand the contexts for using these data elements, we suggest starting at either Pay for Performance (P4P) Initiatives or
Quality Reporting Scenario - Example
Important Date-Related Sub-items to Activate
In order for population registries to be able to determine dates of onset and dates of ending/resolution, the following SMARText sub-items should be displayed for use when creating documentation. In order to activate these, go to Tools in the menubar, and Click Options. Each of the following are list items. Click on each of them and place a checkmark in the boxes in front of the below, bulleted sub-items.
Structured Dx
* Onset
* Resolved
Structured CPT
* Date of Service from
* Date of Service to
Structured Order Entry
* Date,
* Performed Date
Structured Rx
* Start Date
* End Date
Below are some major documentation items to use when reporting "performance" adhering to quality measures. No practice uses all of these, but selectes a sub-set of items.
Encounter SOAP Notes
Objective Field
Vital Signs
Enter vital signs into the Vital Signs section and transfer to the Objective field.
Blood Pressure
Diastolic and systolic - Enter measures consistently.
Height
Enter measures consistently.
Weight
Enter measures consistently.
Assessment Field
- These items can also be entered in the Active Problems field in the Summary.
- Structured Dx SMARText items must be used.
- For proper performance reporting, it is important to activate the Start Date and Resolved Date sub-items and update them as appropriaate over time.
- Also, add SMARText items to the Plan field that are releveant to the diagnosis (see Plan Field, below).
Plan Field
Procedures
Below are listed a few examples:
- Bone mineral density
- Mammogram
- Pap smear
- Colonoscopy
- Flexible sigmoidoscopy
- Echocardiagram/MUGA
- Diabetic foot exam
- Diabetic eye exam
- Diabetic education
These should be entered in the documentation as either Structured Plan Items or Structured Order Entry SMARText items. Until 2010, our advice would be to primary incorporate the former.
Vaccines - Adult
These are documented In SOAP note plan fields as well (i.e. matched to procedure codes). Below are listed a few examples:
- PCV
- Tetanus/Tdap
- Influenza
Vaccines - Pediatric
Pediatric vaccines series complete designation
In order to trigger reminders for vaccines and to create the documentation for performance reporting, start with Health Maintenance rules that are of the Vaccine type. After completing the vaccine information, above, click on the Transfer to SOAPnote button. See Message to Clinicians Regarding Reporting.
See Vaccine Section in Message to Clinicians Regarding Reporting (below is a screen shot from there)
Lab Tests and Other Studies
Need consistent naming of lab items and use of SMARText items for the following labs in Plan fields of SOAP note. Below are listed a few examples:
- Creatinine
- Hemoglobin A1c
- LDL
- HDL
- Triglycerides
- Cholesterol
- Microalbumin
- Microalbumin / Creat Ratio
- Fecal occult blood
- Glucose, fasting
- Glucose, non-fasting
- PSA
- Pap smear
- Chlamydia screen
Referrals
Discrete entry with consistent specialty designation. Search and download SMARText items containing -67 as a keyword. Unique identifiers have been added to these that will make searching/reporting more consistent and complete if you use these items when creating encounter documentation.
Summary - (Past Medical History Issues)
Active and Inactive Problems
The same issues, above, that relate to the Assessment field of encounter notes are applicable here.
Surgical History
Either use the pick list for Surgeries or be certain to consistently enter the name of the surgery without abbreviations (registry reporting is dependent on an exact match of a text string). The following are of particular importance to registries.
Hysterectomy
Mastectomy, bilateral
Splenectomy
**Registry specific.
Medications
Use the Structured Rx SMARText items in the Medications fields in Summary (they have Multum IDs to trigger reporting).
Allergies
Drug and non-drug allergy should be entered into the Allergy field of the Summary.
Later, pick lists will be added so drug adverse reactions can be qualified as allergy vs. intolerance; and type of reaction reported.
Family History
Below are listed a few examples:
- Premature cardiovascular disease in first degree relative - Family History of premature cardiovascular disease (V17.49).
- Prostate Cancer - Family History of prostate cancer (V10.46)
- Breast Cancer - Family history of breast cancer" (V16.3.)
**Registry specific.
Tobacco Issues
Enter appropriate Structured Dx (search on 305.1) for tobacco use in SOAP note Assessments or in the Active Problems in Summary. Plus, include Structured Text SMARText items (Search on P4P**Tob) entered into SOAP notes (primarly Plan, but sometimes Subjective) or Summary, Tobacco field.
**Registry specific.
Social History
Advance Directives
In Summary, Social History, enter the Structured SMARText item with a shortcut of ADR (Advance Directives Reviewed). This could also be placed into the Plan field of an encounter.
"Counseling and discussion regarding advance directives or end of life care. " (E8757)
**Registry specific.
Demographics
Age
Enter DOB in Demographics
Gender
Enter male/female in Demographics
Race or Ethnicity
In SOAPware 2008 and the first release of SW 2010, designate one of the Custom Demographic fields as the location to enter Race. Do this in as consistent of a fashion as is possible. After the initial release of SW 2010, plan to enter discrete race designation from a drop-down list in Demographics.
**Registry specific.
Administrative
Appointments**
Last visit
**Registry specific.
Next visit
Consistent indication in schedule
**Registry specific.
Last Comprehensive Exam visit
**Registry specific.
Next Comprehensive Exam visit
**Registry specific.
Refuse/Decline Any/All Procedures
**Registry specific.
