Intro to Summary
This lesson will cover how to access the Summary chart section and a description of each of the fields contained within the Summary.
The Summary chart section is used for documenting the patients medical history.
Accessing the Summary Chart Section
By default the Summary chart section contains the following fields:
* Active Problems: Current or active medical problems.
* Inactive Problems: Previous or inactive medical problems.
* Surgeries: List of surgeries and/or procedures.
* Medications: Current or active medications.
* Allergies: List of drug and non-drug allergies.
* Family History: Family medical history.
* Tobacco: Past and present tobacco use history.
* Alcohol: Past and present alcohol use history.
* Intervention: Miscellaneous field that may include things such as last significant medial testing and/or lab work.
* Social History: List of social issues such as living situation, support systems, etc.
The following fields are from previous versions of SOAPware and are rarely used in more current versions of SOAPware:
* ROS: Stores a review of systems related to the various organ systems.
* Physical: Stores a physical examination for easy retrieval.
The Default Summary Docuplate
When SOAPware 2010 is installed, the default Summary docuplate will be set to "Summary-DPL" which you can see above. This is a good starter docuplate to use that also allows for an introduction to using SMARText Items and Pick Lists in your Summary documentation. You can modify or set the default to another docuplate if you wish.
There are many different methods and styles for creating documentation within SOAPware. In this introduction to Summary documentation, we will demonstrate the two most common methods of documenting in the Summary chart section.
1. Free Text or Unstructured Data
2. SMARText or Structured Data
Free Text or Unstructured Data
It is not mandatory that you use structured documentation for your patients. You can always document in the Summary chart section as though it was a word processor by just typing the documentation manually. To do this, simply click within one of the Summary fields and type between the bold green brackets as shown above. You can highlight, delete, backspace, and insert text easily using this method of data entry.
Free text data entry is not searchable nor is it reportable for meaningful use. It would be to your advantage to start structuring more of your documentation because it will make you more efficient and give you data that is both searchable and reportable.