Subjective Entry

Free Text

Free Text

The user can always use the SOAP note fields as though this was a word processor and type the documentation manually. To do this, the user will need to click within one of the SOAP note fields and type. The user can highlight, delete, backspace, and insert text easily using this method of data entry.

Comment Box

Comment Box

Using the Item Comment will attach a free-text comment to a SMARText item. In the SOAP Note, Click CHIEF COMPLAINT(S) under Subjective. Notice that an open and a close bracket appears immediately following CHIEF COMPLAINT(S). These brackets indicate that CHIEF COMPLAINT(S) is a SMARText item and that if the user starts typing in these brackets, the user's comment will be associated with the SMARText item, making it more meaningful data.

When the user begins typing inside these brackets, the Item Comment box will appear. After the user types and clicks Save, the comment will be associated with the Chief Complaint.

Structured Text and Quick Access

Click on the CHIEF COMPLAINT(S), again, and notice the pick list displayed in the SMARText Quick Access dialog. The second column in the pick list is the Description. If the Description column is not wide enough, it can be expanded, or the user can point the cursor at the items and the user will see the complete description in a pop-up window. SOAPware recommends using SMARText items like these found in Pick Lists as much as possible. It can make documentation faster as well as make the documentation more meaningful and searchable. Most of this lesson will cover using SMARText Data Entry methods, but at any time the user can use free-text entry if that fits the user's needs best.

Using Quick Access

Using Quick Access

The user will see in SMARText Quick Access Pick List that the Chief Complaint items are listed by system, and that there is an additional item for Most Common Chief Complaints. When the user clicks on any of these lists using the Select box, this will display another list if items in the SMARText Quick Access dialog.

Using Pick List Items

Using Pick List Items

In this second list (Most Common Chief Complaints), click the Description column header to sort alphabetically. The user can click any column header to sort by that column to easily find the item needed.

Selecting a Pick List Item

When the user (1) selects an item, the user will notice that it (2) inserts between the brackets of the CHIEF COMPLAINT(S) data entry area. All of these lists are completely customizable. Each clinician can create their preferred lists of commonly used Chief Complaints.

RFE: Reason for Encounter

RFE: Reason for Encounter

Many visits don't really involve a complaint, but there is always a Reason For the Encounter, and this may or may not be a true complaint. The user will notice that in the description column of Quick Access, many of the items are also RFE items.

HPI: History of Present Illness

HPI: History of Present Illness

The Subjective field also contains a number of History of Present Illness SMARText items. These HPI items present pick lists and function in the same manner as the CHIEF COMPLAINT(S) SMARText items. At this time, consider spending a few minutes clicking around on the HPI SMARText items and their associated pick lists. The user can also look over the ROS (Review of Systems) as well. These pick lists can greatly reduce the amount of time needed to document in the Subjective field, but the user will need to be familiar with them to locate the items needed.

Complaints 2 and 3

Complaints 2 and 3

To add a third or fourth problem, an option would be to utilize the SMARText shortcut codes nexc, nexs or nexd. These codes will insert another, blank Subjective outline. In the screen shot above, the user can see the nexd item.

Multiple Complaints Template

Multiple Complaints Template

There is a Template in the cloud library that will allow the user to document more than one complaint. Start with an empty SOAP Note and hit F5 to use the Quick Entry insertion method.

In the Search field/box, type starterdefault.  This particular Template is designed to be used for two problems.