This lesson will demonstrate how to document in the Summary Surgeries field.
Summary Surgeries Field
The Surgeries field in the Summary is used to record all of the patients past surgical and procedural history.
Placing of the Insertion Point
With a patient chart open and the Summary chart section visible:
- Place the insertion point to the right of the field header.
- Click the mouse to insert the cursor.
If the bold green brackets appear (as shown above), then the field is active and ok to begin entering data.
Recording "No history of any major surgeries" for a Patient
Entering the shortcut SurNo into the Surgeries field and pressing the space bar will expand the structured data need to record documentation if the patient has a negative surgery history.
Entering Surgeries using a Starter Pick List
To enter the Starter pick list for Surgeries, type the shortcut sur- into the Surgeries field then press the spacebar.
*Note: The first time this pick list is used, it must be downloaded from the SOAPware Cloud Library. To download the pick list, type sur- into the Surgeries field and press Shift + F11 on the keyboard. Double-click on the appropriate item in the search results window to download the Pick List to the database.
Accessing the Surgeries Pick List
In SOAPware, text that appears Blue and Underlined indicates that a Pick List is attached to the SMARText Item.
- Click on the pick list header (ie Starter - Surgeries).
- A list of items will appear in the SMARText Quick Access Dialog.
Choosing Items from the Starter Surgeries Pick List
- With the Surgery pick list displayed in the SMARText Quick Access Dialog, check in the box in the Selected column to insert the item into the Surgeries field.
- When the items are inserted, the Starter Surgeries header will disappear.
Attach Comments to a Pick List Item
To attach a free text comment to the SMARText item:
- Click on top of the SMARText item (ie: Appendectomy - see above).
- Begin typing the desired comments (ie: 1998 by Dr. Smith, as shown above). The Item Comment box will only appear after typing has begun. Some users find this process easier by pressing the spacebar after clicking on the item to display the Item Comment box before typing.
- Click Save to insert the comments or press the Enter key.
- The comment will display in the brackets of the SMARText item so they are attached to the item.