SOAPware DocumentationClinical EMR Training ManualsClinical User Manual TemplatesTemplate Toolkit - Getting Started with Documentation

Template Toolkit - Getting Started with Documentation

The following segments introduce some more realistic items that may be used when creating documentation. Take time to play/practice, as this can help provide context, making further learning faster and easier.

Starter Shortcuts

Starter Shortcuts

SOAPnote

  • Subjective: Sub-
  • Objective: Obj-
  • Plan: Pla-
  • Follow Up: Fol- 

Summary

  • Active Problems: Act+
  • Inactive Problems: Ina-
  • Surgeries: Sur-
  • Allergies: All-
  • Family History: fhmu (for Stage 2 MU) or fam- (for non-MU)
  • Tobacco: Tobmu
  • Alcohol: Alc-
  • Social History: Soc-

Using Starters

To use these shortcuts, simply type the shortcut into the corresponding field, then press the spacebar. This will expand the shortcut.

Note: This guide is about getting started; the focus is on simple demonstration, not full support of comprehensive charting. These abbreviated terms are provided only to assist in getting started. They are not comprehensive, and are not intended to contain all the items a user will use.

Additional Starter Shortcuts

  • Subjective: Sub-, Sub--, Sub=, Subt, ROSX, ChiX, nexc, nexd and nexs
  • Objective: Obj-, Objs, Objn, ObjX, ObjX1c, ObjX1n and ObjHA
  • Plan: Pla-
  • Follow Up: Fol-

Starter Templates

Starter Templates

Click Documents in the menu bar, then Click Templates (or Press F6). Check the box to Include Cloud Library Items.  Then type 2008+ in the Search  field/box, and Click the Search button. This search will display Templates that contain SMARText Items. These are also known as New Generation Templates.

Additional Starters - Comparing New Generation Templates

  • PhaC: Pharyngitis or Sore Throat (Compressed)
  • GasC: Gastroenteritis (Compressed)
  • InfC: Influenza (Compressed)
  • URIC: URI - Upper Respiratory Infection (Compressed)
  • DysC: Dysuria (Compressed) Female Cystitis
  • IngToe: Ingrown Toenail (Compressed)

Click on the Template description to select-highlight, then Click the Download button. Even though many of these Templates may be associated with disorders rarely/never treated in the practice, they may be useful in helping provide insight into complementary/alternative work flows.

  • PhaNG: Pharyngitis or Sore Throat (NG)
  • GasNG: Gastroenteritis (NG)
  • InfNG: Influenza (NG)
  • URIC: URI - Upper Respiratory Infection (NG)
  • DysC: Dysuria (NG) Female Cystitis
  • IngToe: Ingrown Toenail (NG)

It may be helpful to reduce the complexity of a downloaded Template item. After inserting the NG Template/template, Press Control + F9 to perform a Remove Unused Items command. This will immediately simplify the Template/template encounter format, revealing the basic organization/framework suggested for the documentation process. New Generation Templates that display many "+" in the generation, contain more SMARText Items.

General Purpose Starters

General Purpose Starters

To find templates that can serve as a plain or generic starter for any type of encounter, check to include cloud library items and search for the term "start"