Just as in Subjective, this default template, has a number of specific SMARText items placed into the Objective field. Clicking on their headers causes Quick Access to display pick list items. In the objective exam, when the exam headers are selected, normal findings are pre-populated in the objective field from SMARText Quick Access.
Vital Signs are recorded in a dedicated chart section and can be transferred to the objective field in the SOAP Note. To learn more about how to use the Vital Signs section, see: Inserting Vital Signs, and Transferring Vitals to the Active SOAP Note.
Growth Charts can be used to plot vital sign readings to track growth. To learn how to use these, see: Growth Charts Interface.
Click the Exam pick list header in the Objective field. A list of exam systems will appear in the Quick Access dialog. The default for this demonstration only displays one of the fourteen exam systems, the GENERAL system.
Exam Systems Data Entry
The user can include any of these exam systems in documentation by checking the box next to the exam system. This will insert the exam as normal in the SOAPDPL Template.
Modifying Normal Exams
To modify a normal exam:
- Click on the pick list before the item to modify.
- Deselect the current pick list item.
- Select the exam finding to include.
By building a customized Template, the user can create custom exams for all of the most common visits. This will help to speed up the users documentation process, while also ensuring that the user is documenting encounters in a meaningful way.