Using Item Comment attaches a free-text comment to a SMARText item. In the SOAPnotes docutainer, click CHIEF COMPLAINT(S) under Subjective. Notice that an open and a close bracket appears immediately following CHIEF COMPLAINT(S). These brackets indicate that CHIEF COMPLAINT(S)is a SMARText item and that if you start typing in these brackets, your comment will be associated with the SMARText item, making it more meaningful data.
When you begin typing inside these brackets, the Item Comment box will appear. After you type and click save, the comment will be associated with chief complaint.
Structured Text and Quick Access
Click on the CHIEF COMPLAINT(S), again, and notice the pick list displayed in the SMARText Quick Access dialog. The second column in the pick list is the Description. If the Description column is not wide enough, it can be expanded, or you can point the cursor at the items and you will see the complete description in a pop up window. SOAPware recommends using SMARText items like these found in Pick Lists as much as possible. It can make documentation faster as well as make the documentation more meaningful and searchable. Most of this lesson will cover using SMARText Data Entry methods, but at any time you can use free text entry if that fits your needs best.
Using Quick Access
You will see in SMARText Quick Access "Pick List" that the chief complaint items are listed by system and that there is an additional item for Most Common Chief Complaints. When you click on any of these lists using the "Select" box, this will display another list if items in the SMARText Quick Access dialog.
Using Pick List Items
Selecting a Pick List Item
RFE: Reason for Encounter
HPI: History of Present Illness
The Subjective field also contains a number of History of Present Illness SMARText items. These HPI items present pick lists and function in the same manner as the CHIEF COMPLAINT(S) SMARText items. At this time, consider spending a few minutes clicking around on the HPI SMARText items and their associated pick lists. You can also look over the ROS (Review of Systems) as well. These pick lists can greatly reduce the amount of time needed to document in the subjective field, but you will need to be familiar with them to locate the items you need.
Complaints 2 and 3
Multiple Complaints Docuplate
There is a docuplate in the online library that will allow the user to document more than one complaint.
Start with an empty SOAPnote and hit F5 to use the Quick Entry insertion method.
In the Search field/box, Type starterdefault. This particular docuplate is designed to be used for 2 problems.