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

Using Item Comment attaches a free-text comment to a SMARText item. In the SOAPnotes docutainer, 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 you start typing in these brackets, your comment will be associated with the SMARText item, making it more meaningful data.

When you begin typing inside these brackets, the Item Comment box will appear. After you type and click save, the comment will be associated with chief complaint.

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 you can point the cursor at the items and you 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 you can use free text entry if that fits your needs best.

You 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 you click on any of these lists using the "Select" box, this will display another list if items in the SMARText Quick Access dialog.

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

When you (1) select an item, you 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.

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. You will notice that in the description column of Quick Access, many of the items are also RFE items.

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. You 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 you will need to be familiar with them to locate the items you need.

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. Above you can see the nexd item.

There is a docuplate in the online library that will allow the user to document more than one complaint.

Start with an empty SOAPnote and hit F5 to use the Quick Entry insertion method.

In the Search field/box, Type starterdefault.  This particular docuplate is designed to be used for 2 problems.