This lesson will demonstrate how to document in the Summary Active Problems field.
Summary Active Problems Field
The Active Problems field in the Summary is used to record an up-to-date problem list of current and active diagnoses for the patient.
Placing of the Insertion Point
With a patient chart open and the Summary chart section visible:
- Place the insertion point to the right of the field header.
- Click your mouse to insert the cursor.
If the bold green brackets appear (as shown above), then the field is active and ok to begin entering data.
Entering a Problem Using Shortcut Codes
To enter a diagnosis using a SMARText Shortcut Code, type the diagnosis shortcut code and then press the space bar (example: type "AlcDep", then press the spacebar to insert Alcohol Dependence ICD# F10.20).
Regarding Shortcut Codes:
- A SMARText item can only have one Shortcut Code.
- Not all SMARText items have Shortcuts Codes.
- Users can add, change and customize all SMARText Shortcut Codes.
Recording "No Problems"
When a patient has a negative history for Active Problems, documentation must be entered as structured data by using the SMARText Item for "No Problems".
Type the shortcut code NoPro into the Active Problems field and the hit the space bar. This will expand into the SMARText item that is required to record that there are no current or active diagnoses for the patient.
*Note: SOAPware users from older versions will need to re-download the NoPro SMARText Item for use within SOAPware. For instructions on re-downloading this item, please see: Using No Known SMARText Item Types in the Summary.
Entering a Diagnosis Using Keywords
To search for a SMARText diagnosis item by using a one word keyword, type the keyword into the Active Problems field (ex: depression) and then press the Shift + F11 keys on the keyboard. The Shift + F11 search will allow the user to view list of diagnosis items that are located on the local library AND on the SOAPware Cloud Library. An F11 search may also be used to view only a list of SMARText items that are on the local library.
Double-click on the desired SMARText Item to enter it into the patient's Active Problems field.
*Note: Shift + F11 and F11 searches can only be performed on one word at a time. For example, if you are searching for Chronic Pain, perform your Shift + F11 or F11 search on either "chronic" or "pain". You can then filter your results if needed.
- SMARText item can have an unlimited number of keywords.
- No SMARText item has every possible keyword that users prefer.
- Users can add keywords to meet their preferences.
- The longer the keyword (i.e. typed entry to search), the faster the search.
Selecting a Diagnosis from a Shift+F11 Search
When items in the cloud library are selected from the pop-up list and inserted (as shown above with depression), SOAPware automatically:
- Downloads the item.
- Adds the item to the local library.
- Inserts the item into the field at the insertion point.
Entering a Diagnosis using a Starter Pick List
The Active Problems starter pick list contains a list of some of the most common diagnosis items.
To enter the Starter Pick List for Active Problems, Type the shortcut code act+ into the Active Problems field then press the spacebar.
*Note: The first time this pick list is used, it must be downloaded from the SOAPware Cloud Library. To download the pick list, Type act+"into the Active Problems field and press Shift + F11 on the keyboard. Double click on the appropriate item in the search results window to download the Pick List to the database.
Accessing the Active Problems Pick List
In SOAPware, text that appears Blue and Underlined indicates that a Pick List is attached to the SMARText Item.
- Click on the pick list header (ie: Starter - Active Problems).
- A list of diagnosis items will appear in the SMARText Quick Access window.
Choosing Items from the Active Problems Pick List
With the Active Problems pick list displayed in the SMARText Quick Access window:
- Users should click in the box in the Selected column next to each of the items that he/she wants to insert into the Active Problems field.
- When the items are inserted, the Starter Active Problems header will disappear.
Diagnosis Sub Items
SOAPware contains several sub-items to assist with maintaining the Active Problems list. The Onset sub-item is required for several Clinical Quality Measures (eCQMs). Please see our Meaningful Use Resource center for instructions on documenting for eCQMs.
Transfer Active Problems to the SOAP Note
An individual diagnosis can be copied to the SOAP Note from the Active Problems list if desired. To do this, right-click on the diagnosis and select Copy diagnosis to SOAPnote.
Setting Default Sub Items: Tools > Options
If a user wishes to utilize any of the diagnosis sub-items within the Active Problems list, the desired sub-items must be defined in the users options.
To define these options:
- Click on Tools.
- Select Options.
Setting Default Sub Items: Structured Dx
- Select Structured Dx from the options menu.
- Click to place a check in the boxes next to the desired sub-items. It is recomended that all users include, at minimum, the Description, ICD#, and Onset sub-items in order to properly document for meaningful use.
- Click on Close.
SOAPware will then require the user to log out and log back in to save the changes. Once the user has logged back in, the newly selected sub-items will now appear by default each time a SMARText diagnosis item is entered.
This is a user-specific setting.