Free Text or Structured Data?

Text Entry Choices

SOAPware offers a variety of different charting methods, permitting great flexibility for information entry. Most use a combination of data entry methods for each section of the encounter and with each patient. One solution will not be sufficient for all chart sections -- just as one shoe does not fit all, one charting method does not fit every type of visit or patient.

Choices of data entry methods include:

Free Text (Typing or dictation)

SMARText Pick Lists and Docuplates/Templates

Speech Recognition (Dragon Naturally Speaking)

Scan in paper encounter forms

Dictate and have transcriptionist type into electronic notes

Scan in your handwritten documentation

Use a Tablet-PC and record the "digital ink"

 

Free Text or Structured Data?

The way in which you actually enter data and document your patient's visits will be one of the most important issues you will address...

Where do you start?

What are your options?

SOAPware recommends taking time for a short 3-question analysis before making this important decision:

What charting method do you currently use?

What are your resources?

What is reasonable and feasible for you and in the best interest of your practice?

 

Reasons to Use Structured Data

If you desire to participate in "Meaningful Use" and "Pay for Performance" (P4P) initiatives, to engage in practice quality improvements, and/or electronic prescribing, then you will need to use structured data.

Note: It is not mandatory that you use structured documentation in your patient charting procedures. However, while using free text may be familiar and seem easier, taking the time to learn more about the benefits associated with using structured data entry could greatly benefit your practice on many levels. Structured data entry not only makes you more efficient, it will also be more likely to allow you to receive greater reimbursement in the near future. In fact, it appears those physicians who choose not to participate in Meaningful Use and P4P initiatives will likely be penalized.

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