Glossary Terms (A-C)
About SOAPware - A menu command under the Help menu that displays information regarding the version of SOAPware that is running.
Active Background - Highlighted area showing the cursor is placed in a field that is active and data can now be inserted.
Active Problems field - Located in the Summary chart section this field is for documenting all medical problems for which the patient is currently being treated.
Active Provider- Located under the SOAPware menu and displays a dialog box of all providers that have a SOAPware license within the practice. The name of the Active also displays at the top of the SOAPware screen.
Addendum - Text that is added to a document after it has been finalized.
Alerts - Pop-ups or reminders. An automated warning system such a clinical alerts, preventive health maintenance, medication interactions etc.
Ambulatory Care - Medical care provided on an outpatient basis.
AMP - An acronym for “Amping up your documentation” suggesting that users begin entering structured data within the Assessment, Medications, and Plan fields.
Allergies field - Located in the Summary chart section this field is for documenting the patient's allergies.
All Refill Requests - A queue under the View menu that houses all pending electronic refill requests for the Active Provider.
Archiver - Located under the Chart menu and is a utility that allows the user to remove inactive patient charts from the Chart Rack.
Assessment field - Located in the SOAPnote chart section this field is to document the patient's diagnosis related to that days visit.
Available Document Designs - An area that lists all available print reports. This area can either be docked, accessed from the Docutainers menu by clicking on Print, or by clicking on the Print button on the common tool bar.
Billing Statement chart section - An area where all Billing Statements are created and stored for the patient.
Bubble Bar - An optional toolbar located at the bottom of the SOAPware screen that allows the user to access other workspaces within SOAPware. The Bubble Bar can be displayed by selecting it from the View menu.
CCR (Continuity of Care Records) - A standardized electronic snapshot of a patient's medical record, demographic and insurance. Data is transmitted in XML enabling a patient's CCR to be shared among any number of providers.
CCR chart section - the area in which CCR records will be stored.
Change Password - Located under the Tools menu this allows the user to change their SOAPware password.
Chart Layouts - Located under the View menu this allows users to create individual chart layouts consisting of tabbed chart sections.
Chart Navigator - Located under the Chart menu (or as a Docked Tab) this area houses and allows the user to access all the patients chart sections.
Chart Rack - Located under the Chart menu this area houses all patient charts and allows the user to create new charts.
Chart Section - Specific areas in the chart to document the patient's medical information. For example: Radiology, SOAPnotes, Demographics etc.
Chart Section Editor - An area located under the Tools menu that allows for the creation of new Chart Sections and setting Default Docuplates.
Clinical Alerts Manager - Located under the Tools menu, this is an area that allows the user to set prompts or reminders when a defined value is found in a specific location. For example, a Diabetes diagnosis in the Active Problems field or a certain CPT.
Contacts - located under the Tools menu, allows you to keep a master list of all referring providers.
Correspondence In chart section - An area where correspondence received from outside the clinic can be stored.
Correspondence Out chart section - An area where correspondence sent out of the clinic, such as consult letters or work excuses, can be stored.
CPOE Computerized Provider Order Entry - CPOE refers to the act of a clinician entering an order for patient services into an information system.
CPT Current Procedural Terminology - The purpose of CPT codes is to provide a uniform language that accurately describes medical, surgical, and diagnostic services.
Custom Demographic Titles - An area that allows the user to define custom patient information such as, emergency contact or guardian information.
Glossary Terms (D-H)
Data conversion - The conversion of data from one software to another.
Data Explorer - Located under the SOAPware menu and is a workspace that allows for specific database searches to be created and performed. For example, all patients with the diagnosis of diabetes.
Demographics - A chart section that contains all basic patient demographic information.
Docked Tabs - Commonly used tools that can be docked to any of the four edges of the SOAPware screen, float or remain locked open.
Document Demographics - Information about the document including a date and time stamp.
Document Importer - A workspace that allows the user to drag and drop documents into a patients chart section without the need to open each individual chart.
Document Management - Allows the clinic to store the patients X-rays, paper reports, Lab reports etc. Document Management includes scanning, dragging and dropping directly into the patients chart and Document Importer.
Docutainers - A hybrid word for Documentation Containers. Most chart sections within SOAPware are docutainers due to the fact that they can contain not only documents but PDFs, video files, images, etc.
Docuplates - A hybrid word for Documentation Templates. Docuplates can be created for almost any chart section and consist of pre-built data entry to allow for speeder documentation.
Document Designer - An area that allows for documents to be created for printing, faxing or storing in the patients chart.
Document History - A history of when a document was created and updated. Also shows by which user and on what computer the document was updated.
Drug Interactions - A feature of the Rx manager that can run an interaction check between the contents of the Active Problems, Mediation and Allergy fields in the Summary against the medications that are being prescribed within the SOAPnote.
Eligibility - Patient insurance eligibility data which can be checked either individually or in batches.
EM Coder - Located under the Tools menu, the EM Coder is the utility that helps the provider determine the level of service to be charged based on documentation.
Encryption - Process of converting messages or data into a form that cannot be read without decrypting or deciphering it.
e-Prescribing - Prescribing medication through an automated data-entry process and transmitting the information to participating pharmacies.
Export - Located under the Chart menu and is a tool used to export a SOAPware patient chart in a format that will allow the chart to be imported into another SOAPware database.
Exit SOAPware - Located under the SOAPware menu this will allow the user to exit the SOAPware program.
Facilities - All clinics that are set up under the Scheduler workspace.
Family History field - Located in the Summary chart section this field is for documenting the patient's medical family history.
Field Header - The beginning of a SMARText data block in a Chart Section.
Financial chart section - An area that houses all financial related documents that do not need a provider's signature. For example, letters from insurance companies.
Flow Sheets - An area to create, store and monitor patient flow sheets.
Flow Sheet items - Located under the Tools menu this allows the user to create and edit flow sheet items.
Follow up field - Located in the SOAPnote chart section this field is for the patients follow up instructions.
Groups - Located under the Tools menu as “Manage Groups” this allows the user to designate a billing provider. Insurance companies identify the providers by which group they are assigned.
Growth Charts chart section - An area that allows users to automatically track growth rates and percentile comparisons for patients over time. The measurements are automatically plotted on a standard, growth chart graph, which can be viewed onscreen or printed out for off line use.
Handouts - Located under the Docutainers menu this allows the user to create, edit and delete patient handouts.
Header (or SMARText Header) - The first word or description of a SMARText item, usually in large dark blue font. For example the name of a medication or diagnosis.
Health Maintenance chart section - The area to track preventative and chronic disease health care.
Health Maintenance Rules and Sets - Located under the Tools menu this area is for creating, editing and deleting Health Maintenance Rules and Sets.
Health Maintenance Rules - Individual items that Health Maintenance can track. An example of this would be an Influenza vaccine or a mammogram.
Health Maintenance Sets - A collection/set of rules. It's a way to group a set of related items together, such as sets of vaccines for age groups or sets of items related to preventative health care for diabetes.
Help - Located on the menu toolbar this contains company contact information as well as access to documentation material and product version information.
HIPAA Health Insurance Portability and Accountability Act - HIPAA seeks to establish standardized mechanisms for electronic data interchange (EDI), security, and confidentiality of all healthcare-related data.
HIPAA Disclosures chart section - An area for storing HIPAA documents.
History and Physicals chart section - An area to store the patient's History and Physicals.
HITECH Act (The Health Information Technology for Economic and Clinical Health Act) - Legislation created to stimulate the adoption of electronic health records (EHR) and supporting technology in the United States. President Obama signed HITECH into law on February 17, 2009 as part of the American Recovery and Reinvestment Act of 2009 (ARRA), an economic stimulus bill.
Glossary Terms (I-P)
ICD-9 or ICD-10 International Classification of Diseases - ICD is the classification and coding of diseases and injuries.
Import - Located under the Chart menu, and is a tool to import a previously exported SOAPware chart into a SOAPware database.
Inactive Problems field - Located in the Summary chart section this field is for documenting the patients past medical history.
Insurance Companies - Located under the Tools menu this is a master list of all insurance companies and related information.
Item Bundles- A SMARText item in which several separate SMARText items can be “bundled” together to be displayed when the Bundle is selected.
Item Clusters - A SMARText item in which several separate SMARText items can be “clustered” together. A cluster is different than a bundle in that clusters have no header to be selected.
Item Groupers - A SMARText item in which several different items can be combined and inserted at the same time with one shortcut code.
Intervention field - Located in the Summary chart section, this field is to record miscellaneous information.
In Use- Located under the Docutainers menu this will show what user is in a locked section of a chart, what computer they are on and the date and time they were in the chart.
Keywords - Provide a method for searching in areas of SOAPware such as Docuplates and SMARText. Keywords are assigned when creating an item or can be added or edited later.
Labs chart section - An area to store in-house labs results or labs done at other facilities.
Lab Tests - Located under the Tools menu and allows for the creation, editing and deletion of specific lab tests and their parameters.
List Options - A section of SOAPware located under the Tools menu that controls what options are available for selection in various drop down locations in SOAPware. Here, you can modify existing lists or remove unused lists or list items.
Lock Layout - Located under the View menu, this removes the ability to X out of a chart section.
Log Out - Located under the SOAPware menu, this will log the user out of SOAPware.
Macro - A SMARText shortcut code that enters a SMARText item or block of text quickly when typed in field and the spacebar is pressed.
Meaningful Use - A set of standards enforced by the American Recovery and Reinvestment Act in addition to HIPAA standards and regulations.
Memo chart section - An area that can hold sensitive patient information for which access can be limited through security settings.
Merger - A utility that allows users to merge duplicate charts.
Messages chart section - An area in which messages such as phone calls, can be documented.
Misc chart section - An area to store miscellaneous documents.
NDC (National Drug Code) - A medical code set maintained by the FDA that contains codes for drugs that are FDA approved. A medication must have an NDC number to be sent via Rx Manager.
Objective Field - Located in the SOAPnote, the Objective field is for documenting the patient's physical exam.
OCR - Optical Character Recognition is the translation of documents into text. OCR works better with simple documents that do not contain images or special characters.
Options - Located under the Tools menu the Options area is where user specific settings are designated.
Order Entry - A utility in which the user can order labs/tests and fax to outside facilities.
Order Manager - Another component of Order Entry in which the user can define specific sub- items before ordering the labs/tests.
Pathology chart section - An area in which to store pathology reports.
Pharmacies - Located under the Tools menu this area is used to search for and download pharmacies that will except electronic prescriptions and manually add pharmacies that accept faxed prescriptions.
Pick List - A type of SMARText item in which a macro or shortcut code has a list of SMARText items associated with it. For example a medication pick list could display a list of commonly prescribed medications for the provider to choose from.
Print - Located under the Docutainers menu this selection will bring up a list of Available Document Designs.
Printed Encounter chart section - An area in which printed patient encounter notes can be stored.
Plan field - Located in the SOAPnote this field is for documenting any CPTs and care plans associated with the patients visit.
PMS - Practice Management System.
Provider Manager - Located under the Tools menu this area houses provider demographic information such as DEA, NPI numbers, and can also store the provider's electronic signature to be imported onto document designs.
Physical field - Located in the Summary section this is a legacy field from earlier versions of SOAPware in which the most recent patient objective exam can be stored.
Glossary Terms (R-Z)
Radiology chart section - An area in which radiology reports can be stored.
Reference Library - Located under the SOAPware menu, this is an area that providers can store reference material.
Re-file- This button, located on the Common Toolbar and under the Chart menu, re-files the chart back into the Chart Rack. CAUTION: Due to CCHIT certification criteria it is possible to re-file a chart that contains unsigned documents. The ability to do this can be restricted through Security settings.
Remove Unused Items - Located under the Edit menu and available by right clicking over any field header, this command allows you to remove any unused SMARText item.
ROS (Review of Systems) field - Located in the Summary section this is another legacy field from an earlier version of SOAPware in which the patients most recent Review of Systems can be stored.
Rx Hub - The ability (in SOAPware 2010.1 and later versions) to check the patient's prescription insurance eligibility.
Rx Manager - The tool used by which prescriptions can be sent electronically, faxed, or printed. A history of medications prescribed and discontinued is kept here as well.
Scheduler - A workspace that manages patient appointments, holiday closings, provider and clinic schedules.
Security - The security system in SOAPware has been set up to help ensure only authorized users are able to access patients' information. Once a user has logged into the system, the security system will track everything the user views and it logs all changes the user makes.
Security Manager - A workspace which allows the user to track users actions within SOAPware. The user must have their own login ID and password to be tracked.
Share Charts - A workspace which allows the user to export all or portions of a medical record to a PDF file.
Signature Password - Signature Password, when enabled, will require passwords to sign off documents and to have multiple providers co-sign on the same documents.
SMARText - A tool to create, edit and use structured documentation that is both searchable and reportable. There are several different types of SMARText items such as diagnosis, CPTs, Medications and pick lists.
SMARText Builder - An advanced workspace which will allow the user to create SMARText Item Clusters and SMARText Item Groupers.
SMARText Color Coding - A setting located under the Tools menu which allows the user to color code specific SMARText items such as pick lists, field headers, and the active background.
SMARText Designer - The area in which a SMARText item is created or the original SMARText item is edited.
SMARText Location Pick List - A user-specific pick list that will display previously used SMARText items in the SMARText Quick Access depending on what field the cursor is active in.
SMARText Manager - Located under the Docutainers menu, this area is for searching for SMARText items and opening the SMARText Designer to create or edit a SMARText item.
SMARText Quick Access - Located under the Tools menu, this dialog box is used in conjunction with pick lists, SMARText location pick lists, and SMARText sub-items. It can be docked for easier access.
SNOMED CT® - Systematized Nomenclature of Medicine – Clinical Terms - SNOMED CT ® is a clinical, health care terminology and infrastructure. SNOMED CT ® contains over 366,170 health care concepts with unique meanings and formal logic-based definitions organized into hierarchies.
SOAPnote - A documentation or progress note format that consists of Subjective, Objective, Assessment and Plan fields. In SOAPware, the Plan field has been further divided to include the Medication Field and the Follow up Field.
SOAPnote chart section - An area in which to document all patient visits and communication.
SOAPnote Medication field - Located in the SOAPnote chart section, the Medication field is used to document and prescribe all the patients medications.
Social History field - Located in the Summary chart section the Social History field is for documenting social issues such as living situation, support systems etc.
Splitter Bar - Located in almost all chart sections, the splitter bars (located above or below a section) can open or close to reveal the document date and stamp as well as other action buttons used to manage the document.
Subjective field - Located in the SOAPnote chart section, this field is for documenting the patient's Chief Complaint, History of Present Illness and Review of Systems. This area is also used to document patient phone calls.
Structured Data - Structured data is managed by technology that allows for querying and reporting against predetermined data types and understood relationships.
Structured CPT- A SMARText item used to document level of service or procedures in the Plan field.
Structured Dx - A SMARText item used to document the patient's diagnosis.
Structured Order Entry - A SMARText item that is used in the Order Manager or with Order Entry.
Structured Rx - A SMARText medication item that can be e-Prescribed.
Summary chart section - An area to record the patients past medical, family and social history.
Summary to SOAP - An option that can be set under the Tools-Options menu that will copy specified areas of the Summary chart section into the SOAPnote chart section.
Summary Medication field - This medication field located in the summary chart section is for documenting all medications the patient is currently taking.
Surgeries field - Located in the summary chart section, this field is for documenting the patients past surgeries and procedures.
Tasks- A reminder located on the user's task list that needs to be completed.
Task Manager- An area in which each user can manage and complete patient related tasks such as refill requests, lab results etc.
Tobacco Field - Located in the summary chart section, this field is for documenting the patient's tobacco use history.
Unfiled chart section - An area in which documents that do not belong in other chart section can be kept. For example, scanned documents from paper charts.
View Previous Encounters - Located under the Tools menu, this utility allows the user to view the patients previous encounters while also viewing the current one. A previous encounter, or part of it, can also be added to the new encounter if desired.
View Signatures - A right-click menu option that displays when a document was signed off, by whom and at what computer.
Vital Signs chart section - An area for documenting and graphing the patient's vital signs.
Workspaces - Areas within SOAPware to manage and record patient care.