Encounter Documentation (Training)

Encounter Overview 

SOAPware derives its name from four items in a provider’s checklist for a patient:

Subjective, Objective, Assessment and Plan. These items assist the provider in documenting the patient encounter.
The SOAP Note contains the provider’s checklist for the patient encounter documentation. As you can see, in the Encounter you just created, it is divided into six fields:

Subjective: The patient’s complaints
Objective: The provider’s examination
Assessment: The provider’s diagnosis
Plan: The provider’s plan for the patient’s care and CPT code if applicable
Medications: The medications prescribed for the patient at this visit/encounter
Follow-up: The follow-up instructions for the patient.

Due to the size of the SOAPware window or the amount of information in the SOAP Note fields, you might not be able to view all the fields at the same time. To view SOAP Note fields that are not currently displayed in the SOAPware window, click the up or down arrows in the vertical scroll bar.

First Encounter 

Previously, we had created a new SOAPnote and your screen should be similar to the one displayed below before beginning.

There are numerous starting points and ways to document an encounter and each have their pluses and minuses. In this example, we will use a mouse driven approach that relies on defining a Chief Complaint. Other methods of encounter creation are discussed in the 'Next Steps' Guide.

Many of the text items in SOAPware are able to help you document - that is SOAPware simply isn't just a word processor. Most items will have a Header displayed in blue text that is underlined to signify that clicking on them will display helpful information. This information is displayed in the 'SMARText Quick Access' tab which by default is docked to the right of your screen. 

This will allow for easier viewing of the pick list items.

The first thing you will notice is that two brackets  will appear when you place the cursor in the Subjective field- these brackets define the start and end points - the data entry area - for  the item. 

Type in chix and hit the F11 key to display the 'Chief Complaint' header.

Click on the blue text labeled 'Chief Complaint'.  

  Also, note that the Quick Access display has displayed a list of groups of Chief Complaints. In the Quick access area place a check mark by the item labeled (Most Common Ch..) you do this by clicking on the empty box to the right of the item you wish to use.

 Now, we see the list of the most common complaints displayed.  Let's place a check mark beside REF- "Sore throat".

 You should see the following:

Without becoming too technical let's discuss what these 'Data Entry' items are. In SOAPware we call these elements SMARText. SMARText elements simply are predefined pieces of information. This information can take almost any form imagined from simple dates to complex lists to complete Medication and Order Entry items.  In the Next Steps Guide we will walk through how to create your own custom SMARText items and how to share them with other users via our revolutionary online Sharing Library.

SMARText usage is optional - at almost any point in a document you can simply type (what we call Free Text) to enter any information that may not fit into a predefined element or to record information using the many different methods of entry.

Continuing on, what we have done is told SOAPware that the primary reason for this visit was that the user was complaining of a sore throat. This information is useful to SOAPware in that it allows the program to display more appropriate selection items in the Quick Access area.

Subjective Entry

First, let's document some Subjective information in a traditional word processing or Free Text method. Click with your mouse to the right of the word Sore Throat you should see the ']' closing bracket now click to the right of this bracket.

Note that the brackets have switched and are now showing us that the data we are about to enter will be part of the Subjective field. Use your keyboard and simply type in your Subjective information - "Patient presents with a persistent cough and claims it is worsened by exercise".

Objective Entry

  Let's enter the Vital Signs for our patient.  Click on Chart on the menu bar then Sections and then Vital Signs. 

Note that the Vital Signs tab is placed where our cursor was last active.  To move this to the left side of the chart for easier viewing while documenting, right click over the Vital Signs tab and select Move to Previous Tab Group.

Now you should have the Vitals Signs tab on the left side of your screen

In the Vitals Signs section click on the first icon with the green plus. Now we have a column with the date and time.

Click in the first box beside Blood Pressure and type in your values. Use your tab key on the keyboard to move down the column.

 Once you have typed in all the values then click on the icon Transfer Vitals.  This will move the values you just typed in the Vital Signs section to the Objective field of the SOAPnote.

 Now let's document the exam for this patient.

Place your cursor in the Objective field below the Vitals Signs values.

Type in the letters objn and hit F11 on the keyboard.

A normal exam is placed into the Objective field.

You will see that there are blue words with underlines and words that are in black.

Click on the words General appearance can be described as, you will see a list of choices to the right of your screen in the Quick Access box.

You can click on other choices or unclick the one that has already been checked.

Continuing to click on the headers with the blue underlines will display choices for you to include as part of the documentation.

You might not need to use every header at every visit.  To remove the unused headers, right click in the objective field and select Remove Unused Items.

This takes all blue text out of the field that does not have any black text beside it, to clean up the note.

Assessment Entry

Now click in the Assessment field. Let's type in pharyngitis and hit  F11. 

The  F11 brings up a list that you can select from.  Double click on PhaA "Pharyngitis, acute" (ICD#462) The text is placed in the Assessment field.

You should see this:

Plan Entry

 The Plan for our patient can include many different items let's use the ordering of Labs.

Click into the Plan Field and click over the word 'Actions'  

Again, by clicking over a blue word will display choices in the "SMARText Quick Access" to choose from.

 Click on "Lab/Test"

Once you click on "Lab/Tests" from the Quick Access area it is placed into the Plan field of your note. 

Now, you can click over Lab/Tests: in the Plan area to display the choices that are available for selection.  Continue to click over the Blue words to display further choices in the Quick Access for selection into your note.

Medication Entry

Click in the Medication field to activate it. You should see the green brackets appear.

We want to prescribe our patient Albuterol today so we can type in Alb and hit F11 on the keyboard.  

This will display a box with Albuterol in it for us to select.

Double click on the Albuterol

In this example we're going to use a more complex Medication SMARText item. To activate the medication click on the Heading 'Albuterol (Proventil, Ventolin)' - again note that the Brackets are now placed around the elements of the medication signifying that we are working the the Albuterol medication.

We're going to introduce a basic optimization now. In the Quick Access display you will see Left and Right pointing arrows - pressing these will move to forward and backwards through your document while activating the next or previous SMARText Item. Press the right arrow. The "Strength" item should activate and the Quick Access display will reflect common strengths for this medication. Click on the 90 mcg/inh (aerosol) item and the Strength should be immediately updated in your encounter. Continue clicking on the right arrow and selecting appropriate items until you have filled out the complete medication.

As you become more proficient with the system you will want to create pre-filled in Medications so that you don't have to manually fill common settings everytime its used. Again, we'll cover this optimization in the 'Next Steps' Guide. We used the above, more round about method, to give you practice navigating through SMARText.

 Follow Up

We have included free text of "Return if problems devleop or worsens" and a SMARText of "Schedule" in the follow up field.  

You can practice your learned skills of navigating through the SMARText items by typing in sfu and hitting the F11 key.  

Congratulations 

  Thats it! You have created your first encounter in the SOAPware EMR. In the next sections we will cover basic patient Summary data entry and then move on to the End of Visit workflows: Printing and ePrescribing a prescription, printing patient handouts and posting a superbill.