The Assessment field is for recording the diagnosis items related to a particular encounter. SOAPware recommends using SMARText Dx items which contain the appropriate ICD code and other relevant sub-items such as onset date.
Location Pick List
Instead of selecting an item from a pre-built pick list, the Assessment field presents an opportunity to utilize a "location pick list". This list works by giving the user choices in Quick Access when the user clicks inside the Assessment field. The choices shown in Quick Access will be dependent on the Chief Complaint entered, as well as the items the user has used previously in the Assessment field and items in this patient's Active Problems list from the Summary.
In this example, with (1) hypertension entered as a Chief Complaint, (2) many hypertension-related diagnoses will appear in our assessment field location pick list. To choose one of these options, simply Double-click on the assessment in SMARText Quick Access and it will insert into the assessment field of the active SOAPnote.
F11 Pick List
To use the F11 Pick List:
- Click in the Assessment field, type a keyword and press F11 to search local items (or Shift+F11, which searches the cloud library as well as local items to return more choices).
- This presents a pop-up pick list below the keyword.
- To narrow search results, type more descriptive words in into one or both filters at the bottom then press Enter or click the magnifying glass.
Scroll through the list to find the most appropriate diagnosis and double click to select and enter the item in the Assessment field.