Glossary Terms

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.

ARRA - American Recovery and Reinvestment Act of 2009

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.

CCD - Continuity of Care Document

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 Decision Support - CMS provides the following definition: HIT functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care.

Clinical Decision Support Rule- An automated, electronic rule based on data elements included in the problem list, medication list, demographics and lab test results.

Clinical Summaries- A summary of each office visit to be given to the patient within 3 business days of visit.  CMS provides the following definition for Meaningful Use Clinical Summaries: An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit, and symptoms.

CMS - Centers for Medicare& Medicaid Services.

CMS Quality Reporting Dashboard- A tool within SOAPware used to export Quality Measures.

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 users 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.

Denominator- The number below the line in a common fraction; a divisor.  A figure representing the total population in terms of which statistical values are expressed.

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.

EHR- Electronic Health Record

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.

Emergency Access Role - A role that set up in Security that allows a user access to all areas within SOAPware in an emergency situation.

Encryption - Process of converting messages or data into a form that cannot be read without decrypting or deciphering it.

EP - Eligible Provider or Eligible Professional.

e-Prescribing - Prescribing medication through an automated data-entry process and transmitting the information to participating pharmacies.

Ethnicity- Refers to selected cultural characteristics used to classify people into groups or categories considered to be significantly different from others such as American Indian, Latinos, Chinese etc.

Exclusion- In terms of Meaningful Use an exclusion refers to an EP excluding a particular Meaningful Use objective because it is not applicable to the EP.

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.

Face to Face encounter- An encounter type that designates the patient had a face to face encounter (office visit) with the provider.

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.

HHS- U.S. Department of Health & Human Services

HIE- Health Information Exchange.

HIMSS- Healthcare Information and Management Systems Society

HIPAA Health Insurance Portability and Accountability Act - HIPAA seeks to establish standardized mechanisms for electronic data interchange (EDI), security, and confidentiality of all health care-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-Q)

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, a user 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.

MAC-Medicare Administrative Contractor.

Meaningful Use - A set of standards enforced by the American Recovery and Reinvestment Act in addition to HIPAA standards and regulations.

Medication Reconciliation- The process of reconciling medications when the EP receives a patient from another setting or provider of care. CMS provides the following definition: The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider.

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.

MU- Meaningful Use.

MU Dashboard - A tool within SOAPware that allows the provider to view a snapshot of their compliance percentage with various MU requirements.

MU (Meaningul Use) Patient Dashboard - A tool within SOAPware used to track the compliance of an individual patient with Meaningful Use requirements.

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.

No Known SMARText Items - Structured SMARText item that can be entered when a patient has no current diagnosis, medications or allergies.

NPRM- Notice of Proposed Rule Making.

Numerator- The number above the line in a common fraction showing how many of the parts indicated by the denominator are met.

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.

Office Visit - CMS offers the following definition: Office visits include separate, billable encounters that result from evaluation and management services provided to the patient and include: (1) Concurrent care or transfer of care visits, (2) Consultant visits, or (3) Prolonged Physician Service without Direct (Face-To-Face) Patient Contact (tele-health). A consultant visit occurs when a provider is asked to render an expert opinion/service for a specific condition or problem by a referring provider.

ONC or ONCHIT-Office for the National Coordinator of Health IT (an agency of the Dept. of Health & Human Services).

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.

Patient Portal- The means in which SOAPware provides patient's access to view their medical records through online access.

Patient Specific Education Resources- Patient education, information or handouts related to the patient's condition.  CMS provides the following definition: Resources identified through logic built into certified EHR technology which evaluates information about the patient and suggests education resources that would be of value to the patient.

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 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.

Preferred Language - The language by which the patient prefers to communicate.

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 CPT's and care plans associated with the patients visit.

PMS - Practice Management System.

Problem List - CMS offers the following definition: A list of current and active diagnoses as well as past diagnoses relevant to the current care of the patient.

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.

Public Health Agency - CMS provides the following definition: An entity under the jurisdiction of the U.S. Department of Health and Human Services, tribal organization, State level and/or city/county level administration that serves a public health function.

Quality Measures- Tools that help measure or quantify healthcare processes and outcomes that are associated with the ability to provide high-quality health care that relate to one or more quality goals for health care.

Glossary Terms (R-Z)

Race- Refers to the categorization of humans into populations or groups on the basis of various sets of heritable characteristics.

Radiology chart section - An area in which radiology reports can be stored.

Record of Disclosures - Used to record disclosures made for treatment, payment and health care operations.

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 the user 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.

Shortcut Code - A SMARText shortcut code that enters a SMARText item or block of text quickly when typed in field and the spacebar is pressed.

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 at Transition of Care- A summary of care record for patient's whom are being referred to or transferred to another providers care.

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.

Syndromic Health Surveillance- The capability to submit electronic syndromic data to public health agencies.

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.

Threshold- The resulting percentage of the denominator divided by the numerator.

Transition of Care (TOC)- When a patient is referred to or transferred to care of another provider. CMS provides the following definition: The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.

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.

Unique Patient- CMS offers the following definition: If a patient is seen by an EP more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure. All the measures relying on the term ‘‘unique patient’’ relate to what is contained in the patient’s medical record. Not all of this information will need to be updated or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period.

Up-to-date- CMS offers the following definition when related to Meaningful Use: The term ‘‘up-to-date’’ means the list is populated with the most recent diagnosis known by the EP. This knowledge could be ascertained from previous records, transfer of information from other providers, diagnosis by the EP, or querying the patient.

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.