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

Accessing the Summary Chart Section
  1. Within the Chart Workspace, open a patients chart.  
  2. Click on the Summary chart tab to display the Summary chart section (as shown above).

Summary Fields

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.
  • ROS:  Stores a review of systems related to the various organ systems.
  • Physical: Stores a physical examination for easy retrieval.

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.

*Note: When a patient has a negative history for Active Problems, Medications, or Allergies, documentation must be entered by using the shortcut to enter the SMARText Item appropriate for each field. Meaningful Use/MIPS requires that the involved fields have structured data recorded.  Please see: Using No Known SMARText Items Types in the Summary for more information.

Default Summary Fields

Default Summary Fields

Summary Documentation

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

Free Text or Unstructured Data

It is not mandatory that the user uses structured documentation for his/her patients.  A user 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.  A user 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/MIPS. It would be to a user's advantage to start structuring more of the documentation because it will make the user more efficient and give the user data that is both searchable and reportable.

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