Set Up Clinician(s)
1. Preferred Chart Layout
There are hundreds of different options when it comes to possible chart layouts. Primarily, the chart layouts deal with the arrangement of tabbed chart sections. Layout preferences are saved per user. This means that anywhere a user logs in on a network, the user's default layout preference will follow. Please look at a couple of the layouts that are available in SOAPware. Eventually, it is likely that each user will customize their own layouts to best meet their preferences. Different layouts are often used for different types of patient encounters.
- The Default Layout:
Notice that for this layout, the Summary, Vital Signs, and Demographics tabs are on the top left. On the top right are tabs for the SOAPnotes, Labs and Radiology tabbed chart sections.
- The 4.X Layout:
This layout is one of the simplest options for a chart layout. The Summary section tab is the only one on the left and the SOAPnotes section tab is the single one on the right.
- The DOCS Clinic Layout:
This layout is the one preferred in the DOCS-clinic. For this layout, the Summary, Vital Signs, Demographics, Printed Encounters and Health Maintenance tabbed chart sections are on the top left. On the right are SOAPnotes, Labs, Radiology, Correspondence In and Flow Sheets tabbed chart sections.
- The Multi Layout:
This layout splits the chart workspace into 3 panes. On the left side, are both Summary and Demographics in view, consecutively. Summary is above Demographics. On the right is a single viewer for the SOAPnote chart section.
For instructions on how to customize Layouts, see: Chart Layouts
2. Select Data Entry Methods
The way in which a user will actually enter data and document patient's visits, will be one of the most important issues a user will address. Users not want to just jump in and make a decision on this without first doing an analysis.
Questions for a user to ask him/herself include:
- What is the user doing now?
- What are the resources?
- What is reasonable and feasible?
- Below is a set of questions that are designed to help the user narrow down the options. Based on the answers, we offer some suggestions.
- Does the user desire to participate in "Meaningful Use" and "Pay for Performance" Initiatives, and to engage in practice quality improvements, and/or electronic prescribing?
If No, then it is an option to use free text.
It is not mandatory that a user enters structured documentation for patients. However, while using free text may be familiar and seem easier, it would greatly be to a user's advantage to investigate how he or she can start structuring more of the documentation. It will not only make the user more efficient, but it will also be more likely to allow the user to receive greater reimbursement in the near future. In fact, it appears those not participating in meaningful use and P4P initiatives will likely be penalized.
If Yes, the key to being able to participate with the new initiatives is to ensure that the Assessment, Plan and Medications sections within encountered notes are structured. Other sections of encounter documentation (i.e. Subjective, Objective) have less need for structured data entry at this point in time.
There are a number of different charting methods available in SOAPware offering great flexibility in how information can be entered. Most use a combination of data entry methods. Users have a choice with each section of the encounter and with each patient. More than likely, 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 methods for data entry include:
- Free Text (Typing or dictation)
- SMARText Pick Lists and Templates/Templates
- Speech Recognition (Dragon Naturally Speaking)
- Scan in paper encounter forms
- Dictate and have transcriptionist type into electronic notes
- Scan in handwritten documentation
- Use a Tablet-PC and record the "digital ink"
3. Define "Top 20" Usage Lists
- Diagnosis Codes
- CPT Codes
- Patient Handouts
- Reason for Encounters or Chief Complaints
Defining the above usage lists, a user will have a great head start to downloading or creating customized templates or "Templates" to use for encounters. As well as the user's Top 20, consider looking at the clinic superbill for more items frequently used.
4. CPT-Coded Item Setup
During initial set up, it is important to take all the procedure codes on the clinic's Superbill and confirm they are downloaded locally. These are SMARText items of the Plan item type.
Have each clinician that will be entering procedure codes, look at each downloaded term from the Superbill list, and indicate how they would do a search for that term. If the clinician's choice of search words is not in the description, check to see if it is included as a keyword. If not, then we suggest contacting SOAPware, so that we can add it for all SOAPware users. Send an email message of suggestions to [email protected]
Over time, create Templates that include pick lists having procedure items that only include those preferred and with verbiage the clinicians prefer.
SMARText is a toolkit containing all the tools (i.e. all the CPT codes). But, it is important for clinicians to realize that the descriptions that accompany the codes are often not the ones that are familiar.
For example, searching for x-ray only retrieves those items that SOAPware has added x-ray as a keyword. This is because the CPT descriptions use the terms radiological exam instead of x-ray.
Sometime after initially going live with SOAPware, start introducing order entry items in addition to the plan items that contain CPT codes.
5. Diagnosis Item Setup
It usually comes as a shock to most physicians how much inconsistency is present as to the selection of diagnoses among different physicians in different specialties and localities. It also typically comes as a shock to learn how varied are the terms that individual physicians prefer to utilize to describe the same diagnosis.
The Cloud Library includes the ICD-9 codes within SMARText items of the Structured Dx type. But, it is important for clinicians to realize that the descriptions that accompany ICD-9 codes are often not the ones that are familiar.
No EMR, out of the box, is going to be able to generate a simple list such as this that is going to reflect what any individual clinician expects and using the wording any individual clinician prefers.
The ICD-9 terms/descriptions, in original form are very limited. Each word in the description is a keyword that can be searched. And, SOAPware is in the process of adding thousands of keywords on a monthly basis. Again, when SOAPware users need a keyword added, we invite them to send an email message of suggestions to [email protected]
A few clinicians strongly prefer to enter common diagnoses using the shortcut entry method. Notice that the diagnosis items that have been edited (i.e. descriptions enclosed in double-quotes), often have tentative shortcuts added as well. The shortcuts can also be changed to meet user preferences. Several considerations have led to the shortcuts that are included within edited diagnosis items in the Cloud Library. These are simply included for convenience, and clinicians are encouraged to edit them to create ones they prefer and can remember.
6. Default Template Setup
NOTE: The default SOAPnote Template when SOAPware is installed is for getting started/introduction purposes only. It needs replacement once users have completed the initial Introduction to SOAPware.
Templates allow common sets of document items for various chart sections to be saved and reused later. This capability is particularly useful for documenting common conditions seen repeatedly. They are also great tools for implementing Best Practice Guidelines and more consistency in documentation.
A user will want to have a Template set up as the default, as well as Templates for specific visit types.
For information on downloading, using, and creating Templates, see Templates.
7. Order Entry Setup
To prepare for using Order Entry in SOAPware, it is recommended that you download all order items that are commonly used in your clinic. You can download the order items from the SMARText Items Manager (F10).
In order to download the Order Entry items needed in the practice:
- Make a list of the most frequent orders in the practice.
- Search the SOAPware Cloud Library for these Order Entry items and download the appropriate ones.
- Customize the downloaded orders. Rarely should the user need to create new ones.
If users are not ready to identify and download the items his or her will need, but want to explore the use of Order Entry, here is an alternative means to get started. In order to obtain a set of the generally most common starting order entry items, search and download the order entry items containing the keywords---- (i.e. s and 4 dashes).
To download these items, Click Documents in the menu bar, and click the SMARText Items menu item (or Press F10 key). In the Type column, the Order Entry can be identified. (Clicking on the Type column header will group together the items). Select/Hightlight the items to download and click the Download button. Users can download them one by one, or select multiple items at once by holding the control or shift button.
For orders that are not available on the Cloud Library users can create custom order entry items. Users can also modify existing order entry items to include the sub items her or she wants to include with the order.
For instructions on downloading and creating orders, see: Order Entry Set Up.
8. Patient Handouts
Paper-based patient education handouts can be used in SOAPware and printed automatically from the patient's chart. Now is the time to decide what handouts the user would like to include. There are many available on the Cloud Library and the user can edit these to customize them as well as create brand new handouts. To learn how to download, edit, and create handouts, see: Handouts.
9. Structured Text Data Entry
SMARText is a type of data entry that is unique to SOAPware. It was created by associating hidden information to the words and phrases used in documentation. This results in the documentation being able to be identified electronically and read by computers. Simply put, SMARText is a Lego set for medical information. Just like the Lego's of a user's youth, SMARText has many different pieces that can be put together in almost limitless ways. The "pieces" in SMARText are called items and they are of many differing types.The Type defines what the SMARText item may contain, represent, and do.
For example, within SOAPware, all the CPT/HCPCS items, ICD-9 items, and medications have each been associated with specific SMARText items for immediate use when creating documentation.
Users will see that with SMARText, users will be able to:
- quickly and easily associate information that needs to be grouped together (i.e. a SMARText item of the appropriate type)
- do it all in one location (i.e. a SMARText item of the appropriate type)
- save it for reuse in the future (save it in the SMARText library)
10. More Data Entry Options
SMARText items (except for Order Entry) can be arranged into pick lists, and be selected by simple clicking. So, they function much like a paper superbill, where the individual would either circle or check boxes. Customized pick lists are one of the most efficient data entry methods. Create custom pick lists containing the items that the user commonly-repeatedly utilize. Pick lists allow the user to perform data entry via a click for an item the user would desire to insert into documentation.
Templates are simply stored templates for encounter notes, procedure notes or just about any section of the chart. A user can have Templates for not only SOAPnotes (encounters), but also for Flow Sheets, Labs, Patient Summary, Drawings, etc. In regards to documenting a SOAPnote, a user can have a Template that has some free text in one section, some SMARText items defaulted in another, and several different pick lists inserted.
In general, there are 2 main approaches to use Templates:
- Set up a Template for each of the most common appointment types or chief complaints.
- Set up a generic or "general" Template that is used for all types of visits. Typically, these generic Templates/templates require a little more data entry at the time of the encounter than those designed for particular types of encounters.
Customize Wording, Appearance, Order, and Spacing of SMARText
It is not usually apparent, when starting, that almost any clinician can use SMARText items and have the final appearance of the documentation appear exactly as they prefer. For example, the Chief Complaint SMARText item could be changed to CC if preferred.
Free or Unstructured Text
Free-text or unstructured data entry involves nothing more than clicking into a field and typing away. So, free-text is the same as simple typing into Microsoft Word or other word-processing document. Obviously, free text typing can be by the clinicians, assistants or transcriptionists, and should be minimal by the clinicians. There are some considerations when working with free-text in SOAPware.
Dictate and Use Transcriptionist
Some doctors choose to dictate, and have their transcriptionist document directly into the electronic SOAPnote. This is not very efficient for the long term, but can be a transitional workflow when trying to migrate towards more modern-efficient documentation.
Dragon Naturally Speaking
Dragon Naturally Speaking is a speech recognition software that allows the user to dictate into a microphone at the computer, and the software translates spoken words to text in real time. Users are able to dictate directly into SOAPware in order to make data entry easier and more efficient.
Dragon Naturally Speaking is a separate program that works in conjunction with SOAPware. Contact the SOAPware Sales dept at 800.455.7627 for pricing and details. See the links below for illustrations of Dragon and SOAPware:
Getting Started with Creating Documentation
Consider creating a Template for each of the 10 most common encounter types or reason for encounters in the practice. When creating these Templates, a user will need to go through each section and determine if the user wants to just have defaulted text for that section or would like to pick from a list, etc. Again, the Assessment, Plan and Medications fields are most benefited by structured information. Particularly, in the beginning, the user may want to mostly use free-text into the Subjective and Objective fields. This is especially the case for those converting from other free-text based EMR's. When the user gets to the Assessment field, plan to start transitioning to structured entry. For example, a user might want to default a pick list of SMARText items Structured Dx/Assessment items containing the ICD codes needed for billing. Similarly, consider the same for the Plan field, and for the Medications field. Electronic prescribing results in the use of Structured Rx/Medications, by default.
Another tool most use, to some degree, is to have particular SMARText items that are almost always used, and rarely change, already entered into starting Template/templates.
Once a user has created these Templates/templates for a user's 10 most common types of visits, just insert them into future encounter notes and edit as needed. A user can create as many or as few Templates as needed. It is all up to the user. A user could start with 5 or with 20.
11. Schedule Set-Up
This section is designed to help the user set up the schedule, and plan for the days to block off for various reasons (ie. vacation, conferences, catch up days, etc.) If the user has numerous clinics amongst which he or she travels, the user will want to make sure the clinic rotation is accurately reflected on all various facility schedules.
There are three main sections here: Provider/Resource Management, Business Hours Management, and Facility Closings.
In this area, should be a list of licensed providers for the site. If the provider is not already in this list, the provider likely does not have a license to the Scheduler. This area is the location to actually activate the providers/resources that will be using the Facility.
Working Hours Management
This section allows the working hours for the Provider/Resource to be set for the facility. If the user has multiple facilities, among which a Providers/Resource travel, set the days and hours that each will be working at each facility each week. These times that are set up will then be available for scheduling for each Provider/Resource.
This allows the set up of regular blocks for a provider at the facility. For instance, if the provider regularly takes lunch from 1pm-2pm on the days she/he is at the facility, set that time from this section.
Business Hours Management
Set the overall operating business hours for the facility in this section, regardless of the provider that is there. Changing this section will be identical to setting the hours for a provider in the Working Hours Management section. This should be relatively simple to update and edit.
Block off the days the clinic will not be open to see patients, or is closed entirely for holidays, etc. Notice this section applies to the overall facility regardless of the provider.
12. Tools - Options
When SOAPware is installed, it includes certain defaults and settings that can be changed whenever needed. The Options dialog contains numerous, miscellaneous options to allow SOAPware to best match the user's preferred needs and work-flows.
To see all of the options settings, see: Tools - Options.