SMARText Item Types

Every SMARText item is designed as a specific type. The type chosen tells SOAPware the characteristics of that SMARText item such as what kind of data to expect, what the item can do, and how the item can be designed.

First Level View of SMARText Item Types

First Level View of SMARText Item Types

In order to see the current list of SMARText Item Types available:

  • Click Docutainers > SMARText Items, from the main menu, or Click F10 on the keyboard.  
  • Click on the green plus, which will bring up the SMARText Type Selection box.  
  • Select "Custom," and Click on the drop-down arrow.  
  • Lastly, Click on the expander node next to "Generic" as shown in the screen shot above, to see the first level view of the SMARText Item Types available.  Should a user want to see all of the SMARText Item Types, Click on the expander nodes next to each first level SMARText item.

First Level - Basic Items

First Level - Basic Items

1.  Free/Unstructured Text (Misc (US))

Unstructured text is the simplest of all the SMARText item types, as it is free-text.  It has no value to the computer, with its lack of codes attached to it for searching/sharing purposes, but can be useful when a user needs to insert typed words, sentences, or even paragraphs of text.  For those who converted from Version 4, all previously created SMARText items will convert as unstructured text.

For more information on unstructured text, see: Shortcut Code.

2.  Structured Text

The advantage of the Structured Text SMARText item type is that the data inserts an object of text that cannot be altered and can be fully coded. Therefore, this item type is often chosen for the individual SMARText items that are listed within pick lists.

For more information, please review the Data Entry in SOAPware chapter within the Clinical 2012 User Manual.

First Level - Controls

 First Level - Controls
  1. Number Picker SMARText Item: A user would utilize the Number Picker SMARText item type if he/she wanted to document information that could be best displayed with a number.  To view this lesson, see: Number Picker SMARText Item.
  2. Date Time Picker: A user would utilize the Date Time Picker SMARText item type if he/she wanted to document information that could be best displayed with a particular date or time.  To view this lesson, see: Date Time Picker SMARText Item.

First Level - Entry Fields

First Level - Entry Fields

Focusing primarily on the Generic Encounter and Generic Summary Fields....these Generic types allow for new fields to be defined within SOAPware.  For more information, see Create Custom Field Headers.

First Level - Exam Systems

 First Level - Exam Systems

In the screen shot above, all the physical exam systems, plus a generic type system, are listed.  These Exam System SMARText item types have been defined by the CMS/AMA.

For more information regarding Exam Systems, see: EM Coder: Exam.

First Level - Lists

First Level - Lists

1.  Multi-Sel List

This SMARText item type presents a display of SMARText items to which the user can select one item, or multiple items, to insert into the documentation.

For more information on Multi-Sel Lists, see: Creating SMARText Pick Lists.

2.  Single Select List

This SMARText item type presents a display of SMARText items to which the user can only select one item.

For more information on Single Select Lists, see: Single Select Lists.

3.  Toggle Multi-Sel List

Toggle Multi-Sel Lists are created "from the ground up," meaning, the user is to first create each component prior to putting the toggle together as a whole.  

Structured Text SMARText items will be the components that will be used to "toggle" between, in the user's documentation.

For more information on Toggle Multi-Sel Lists, see: Creating Toggles.

4.  Item Clusters and Item Bundles

Item Clusters offer larger, initial pick lists with less need for branching.  All of the items within a cluster will be displayed at once, automatically.

Item Bundles offer a branching, hierarchical approach, which displays smaller pick lists. Bundles allow for the bundling of a group of items, to which not all the items are displayed initially.

For more information on Clusters and Bundles, see: Create Item Clusters and Bundles.

5.  Item Groupers

Item Groupers are SMARText items that, when inserted to a patient's chart, enter multiple pick lists, in a particular sequence, at one time.

For more information on Item Groupers, see: Create an Item Grouper.

First Level - Objective Items

First Level - Objective Items

1. Findings

Findings are the 50+ exam elements that comprise the suggested framework to use when creating documentation.  If these are present in documentation, they will automatically score exam points for the EM level of visit coding.  These items are created by SOAPware and we recommend their use first, however, a user can customize such items.

2.  Specific Findings-Exam Generic Findings Specific

Exam Generic Findings Specific items types are specific findings on examination and are usually associated with a Findings item.  They are usually found within pick lists associated with Findings items.  

For more information regarding EM Coder and the Objective Field, see the following links:   EM Coder: Exam and Objective Entry.

First Level - Plan Items

First Level - Plan Items

Plan items are SMARText item types designed for use in the Plan field.  They are designed to record and measure some of the decision making elements as defined by the CMS/AMA, to be used in EM Coding of level of service.

1. DM DataSubset Findings

This type of finding is comprised of the 8 decision making categories as defined by the CMS/AMA for EM Coding.

2.  DM DataSubset Findings Specific- Generic Finding Specific

This item type is most commonly used to fill in the specific findings within the DM DataSubset Findings.

3.  Plan Item

Plan items are similar to the Generic Finding Specific type, however, these plan items generally contain CPT codes.

For more information regarding EM Coder and the Plan Field, see the following links:  EM Coder: Exam and Plan Entry.

First Level - Structured Items

First Level - Structured Items

Structured SMARText items may be created for direct insertion into a patient's chart. They can also be created to add to a pick list, bundle, cluster or toggle.

A few benefits of creating structured text items include:

  1. Structured text able to be searched using the Data Explorer.
  2. Since structured text is easier to search, it may allow the user to be prepared for future Meaningful Use (MU) and Patient Centered Medical Home (PCMH) initiatives.

*Note: SOAPware first recommends searching for a desired Structured SMARText item through our SMARText Items Manager, as these items are SOAPware created and contain CMS/AMA approved codes, however, a user is able to customize an item if need be.

1.  Assessment Item

Assessment Item = Type--Dx...used within the Assessment field within the SOAP Note.  A diagnosis will be inserted and will be paired with an ICD-9 code, making reporting and searching data easier.

For more information, see: Assessment Entry.

2.  Medication Item

Medication Item = Type--Rx...used to prescribe, print and fax prescriptions from within the Medications field within the SOAPnote.  

For more information, see: Medication Entry.

3.  Plan Item

There are four types of SMARText items that are utilized in the Plan field within the SOAPnote: Immunization Order, Misc Information, Order Sets, and Orders.   Whether entering a Plan SMARText item through the Actions pick list, or entering one individually, a CPT code will be attached, making searching and reporting data simpler.

For more information, see: Plan Entry and Order Entry.

First Level - Subjective Items

First Level - Subjective Items

All of these items in the previous screen shot are used within the Subjective field within a SOAPnote.

  • Chief Complaint- The main header...Chief Complaint(s)/Reason for Visit.
  • Chief Complaint Specific Findings- The actual list of chief complaints used in documentation.
  • HPI- The main header...HPI.
  • HPI Findings- The 8 HPI pick lists.
  • HPI Specific Findings- The actual list of HPI items used in documentation.
  • ROS- The main header...ROS.
  • ROS Findings- The 14 ROS pick lists plus a generic pick list.
  • ROS Specific Findings- The actual list of ROS items used in documentation.

For more information, see Subjective Entry and HPI.