Recent Updates

  • Updated on: Jul 06, 2017

    Plan Entry

    The Plan field is for recording office visit CPT codes as well as any labs, radiology, or referrals that may be ordered for the patient.  For Meaningful Use, orders must be placed through the order manager then they are automatically inserted into the Plan field.  Another MU requirement is to provide the patient educational materials, and this should also be documented in the Plan field using the workflow described below.

    Manual Clinical 2011 User Manual
    entry handouts lab plan related dx tests

  • Updated on: Jul 06, 2017

    Objective Entry

    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.

    Manual Clinical 2011 User Manual
    exam growth chart objective systems vital signs

  • Updated on: Jul 06, 2017

    Subjective Entry

    Manual Clinical 2011 User Manual
    comment box free text HPI pick list Quick Access RFE structured text subjective

  • Updated on: Jul 06, 2017

    The Default Template

    The default template is automatically entered when a SOAPnote is created. When SOAPware is installed, the default template will be set to "SOAPDPL".

    Manual Clinical 2011 User Manual
    default docuplate template soapdpl SOAP note

  • Updated on: Jul 06, 2017

    Creating a SOAP Note

    This lesson discusses creating a SOAP note.

    Manual Clinical 2011 User Manual

  • Updated on: Jul 06, 2017

    SOAP Charting

    SOAPware derives its name from the SOAP format used for encounter documentation (i.e. Subjective, Objective, Assessment and Plan).  

    In SOAPware, the legacy format for encounters is for the Plan to be further divided into two (2) fields:  

    1. Medications
    2. Follow-up
    Manual Clinical 2011 User Manual
    charting documenting SOAPnote SOAP note subjective objective assessment plan follow up soap

  • Updated on: Jul 06, 2017

    Lab Templates

    This lesson will cover how to search and create lab Templates.

    Lab Templates are used for documenting groups of lab tests.  For example a CBC is composed of many lab tests: WBC, RBC, Hbg, Hct,  etc.   A lab Template for a CBC would contain all of the individual tests that make up that CBC.  

    Manual Clinical 2011 User Manual
    docuplates lab templates lab templates

  • Updated on: Jul 06, 2017

    Creating and Editing Lab Tests

    This lesson will explain how to create individual lab tests with reference ranges.  These lab tests can be pulled into lab Templates for documentation of lab results in the clinic  Lab Templates will be discussed in the next lesson.

    Manual Clinical 2011 User Manual
    lab tests Lab Tests lab test editor

  • Updated on: Jul 06, 2017

    Inserting Vital Signs

    * REQUIRED FOR MEANINGFUL USE

    • Stage 1 & 2: Record Vital Signs
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    vital signs vitals insert vitals record vital signs

  • Updated on: Jul 06, 2017

    Add / Edit Vital Reading Date

    * REQUIRED FOR MEANINGFUL USE

    • Stage 1 & 2: Record Vital Signs
    Manual Clinical 2011 User Manual
    vital sign vitals add reading date add vitals record vital signs