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 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"

Free Text or Structured Data?

The way in which a user actually enters data and documents his/her patient's visits, will be one of the most important issues the user will address...

  • Where does the user start?
  • What are the user's options?
  • SOAPware recommends taking time for a short 3-question analysis before making this important decision:
  • What charting method does the user currently use?
  • What are the user's resources?
  • What is reasonable and feasible for the user and in the best interest of the user's practice?

Reasons to Use Structured Data

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

*Note: It is not mandatory that the user use structured documentation in his/her 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 the user's practice on many levels. Structured data entry not only makes the user more efficient, it will also be more likely to allow the user 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.