Objective Entry

Just as in Subjective, this default template/docuplate, has a number of specific SMARText items placed into the Objective  field. Clicking  on their headers  causes Quick Access to display pick list items. In the objective exam, when the exam headers are selected, normal findings are pre-populated in the objective field from SMARText Quick Access.

Vital Signs

Vital Signs are recorded in a dedicated chart section and can be transferred to the objective field in the SOAPnote. To learn more about how to use the Vital Signs section, see: Inserting Vital Signs and Transferring Vitals to the Active SOAPnote.

Growth Charts

Growth Charts can be used to plot vital sign readings to track growth. To learn how to use these, see: Growth Charts Interface.

Exam Systems

Click the Exam pick list header in the Objective field. A list of exam systems will appear in the Quick Access dialog. The default for this demonstration only displays 1 of the 14 exam systems, the GENERAL system.

Exam Systems Data Entry

Exam Systems Data Entry

You can include any of these exam systems in your documentation by checking the box next to the exam system. This will insert the exam as normal in the SOAPDPL docuplate.

Modifying Normal Exams

Modifying Normal Exams

To modify a normal exam:

1. Click on the picklist before the item you would like to modify

2. Deselect the current picklist item

3. Select the exam finding you want to include

Customizing Exams

By building a customized docuplate, you can create custom exams for all of your most common visits. This will help to speed up your documentation process, while also ensuring that you are documenting encounters in a meaningful way.


Add your comment

E-Mail me when someone replies to this comment