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TEMPLATES & CODES:  DOCUMENTATION METHODS IN SOAPware.

Code - is a shortcut used in encounters to expand a string of text into a field (Assessment, Plan, Medication, Follow-up, or Various.)  For Example:  'tyl3' is a Medication Code that expands to 'Tylenol #3 Tabs (Disp - #30) Take one or two every 4 hours as needed for pain (Refills-0)' - this code will only work in the Medication field.  A code will only work in the field that it is assigned, unless it is a Various Code, in which case it will expand in any field including Subjective, Objective, & Summary.

Template - is a shortcut used in encounters to expand a long, repetitive Examination Outline into many fields at once.

Creating a Template (from an existing template):

• Open a Chart, example: Slim Jim.

• Create an encounter.

• Starting with an already existing template.  Go to: View > Template List > click on or type the letter 'i' > scroll down, select 'Influenza Simple', and then click on insert.  (This is a very simple, narrative style template).

• Notice that the template has now been inserted into the encounter & all of the SOAP fields have some form of documentation in it.

IMPORTANT:  At this point you can edit anything within the template to better fit your style of practice. 

• After you have made your changes, go to: Edit > Create Template. 

• A window appears that asks "Please enter a code for this template:" - do so & click OK.  Another window will appear that asks "Please enter a description of this templates:" - do so & click OK.

• At conclusion:  a new template will have been saved & ready for use or a message, will say "A template already exists with this code.  Continuing will override the current template."  Clicking OK will override the old template or clicking cancel will remove you from the template creation process, thus allowing you to examine your duplicate code situation.

New templates can be created by going to:  View > Template List > clicking New, creating the selection, & then clicking Save or with the above instructions, but start with an encounter with no template inserted.

Editing templates can also be accomplished by going to:  View > Template List > selecting an existing template, clicking View, editing the selection, and then clicking Save. 

Why are periods & colons important?

If you decide to use double underlines in your templates, then it is very important to know that whenever you add text after a period or colon, you must end that text with a period.  If you do not, then the text that you had entered will be removed when you remove unused underlines.

When the double underline method is used in the templates or expander codes, SOAPware is designed to read from period to period or period to colon.  So, the text to the left of a period or colon will be saved when removing unused underlines.

Example:  When you remove the underlines, it looks for a UNDERLINE then goes to 1st period on the right & then removes everything to the left of it until it runs into another period or colon.  Four words to the left of the colon will be bolded after the Remove Underlines is clicked.

        "I took a test.  The score is __."     Click Remove Underlines    "I took test."

        "I took a test.  The score is: __."    Click Remove Underlines    "I took a test. The score is:"

Ctrl-Q is another template shortcut, it removes the underline immediately to the right of the cursor.   Also the F5 key is a simple way get a template inserted into an encounter, if you know the shortcut code.

What is point and click?  The 3 Tools of SOAPware Templates.

You will notice that many of the templates that are already in SOAPware have a certain format that include what we call 'double underlines' or 'double underscores,' which look like this; __.  These double underlines are used to choose already recorded documentation within a template. 

By placing the cursor over the double underline and left-clicking your mouse, it will change to a (+),

      CHIEF COMPLAINT: Chest Pain__.

      CHIEF COMPLAINT: Chest Pain(+).

Click again and it will change to a (-),  

 CHIEF COMPLAINT: Chest Pain(-).

Click again and it will return to a double underline,  __.  

After you have used a template that uses the double underlines, then you must 'clean it up' by removing the unused underlines.   

Before underlines are removed:

     CHIEF COMPLAINT: Chest Pain__.

HPI:

ONSET/TIMING: Onset __ days ago. Sudden(+). Gradual__. Today__. Yesterday__.  3 days ago__. 4 days ago__. 5 days ago__. 6 days ago__. 1 week ago__. 2 weeks ago__. 3 weeks ago__. 4 weeks ago(+). 5 weeks ago__. 6 weeks ago__. 1 month ago__. 2 months ago__. 3 months ago__. 4 months ago__. 5 months ago__. 6 months ago__. Recheck__. Work related__.

DURATION: __.--Continuous__. Intermittent__. Chronic__. Acute__.

QUALITY/COURSE: __. --Worsening__. Improving__. Unchanged__. Sharp pain__. Dull pain__. Burning pain__. Heavy__. Squeezing__. Constricting__. Suffocating__. Crushing__. Sharp(+). Stabbing__. Pleuritic__.

LOCATION: __.--Bilateral__. Right__. Left(+). Retrosternal(+). Shoulder__. Arm__. Neck__. Jaw__. Radiation to __.

INTENSITY/SEVERITY: __.--Mild__. Moderate__. Severe(+).

CONTEXT/WHEN: __.--Similar problems(-). Physician visits__. Exposure_to_others_with_similar_symptoms__.

MODIFIERS/TREATMENTS: Tylenol and Ibuprofen(+).--None__. Exertion(+). Stress__. Cold exposure__. Large meal__. Pressure to chest__. Cough(+). Breathing motions__. TNG__.

SYMPTOMS/RELATED: __. Unchanged__. Possible medication side effects include__. EKG__. CBC__. Cholesterol__. Chest X-ray__. Cardiology Consult__. Treadmill stress test__. Coronary angiography__.

REVIEW OF SYMPTOMS: __. Fever(+). Chills__. Fatigue(+). Dyspnea__. Dyspnea on exertion(+). Paroxysmal Nocturnal Dyspnea__. Orthopnea__. Diaphoresis__. Palpitations__. Nausea(+). Vomiting__. Weakness__. Diaphoresis__. Syncope__. Near syncope__. Cough__. Sputum production__. Hemoptysis__. Anxiety__. Depression__. Stressed__. Weight loss__. Weight gain__. Leg Pain__. Dizziness__.

To do this, you can go to the Edit > Remove Underlines > on the SOAP side.  Now, all that is left in the encounter is the headings and the text that had a positive or negative.

Note: you can remove the underlines in a single SOAP field by right clicking your mouse.  This will show you the menu related to that field, then click on the item that says "Remove Underlines."

After underlines are removed:

CHIEF COMPLAINT: Chest Pain(+).

HPI:

 ONSET/TIMING: Sudden(+). 4 days ago(+).

 DURATION: Acute(+).

 QUALITY/COURSE: Sharp(+).

 LOCATION: Left(+). Retrosternal(+).

 INTENSITY/SEVERITY: Severe(+).

 CONTEXT/WHEN: Similar Problems(-).

 MODIFIERS/TREATMENTS: Tylenol and Ibuprofen(+). Exertion(+). Cough(+).

 SYMPTOMS/RELATED:

 REVIEW OF SYMPTOMS: Fever(+). Fatigue(+). Dyspnea on exertion(+). Nausea(+). 

In the Objective field, the principle is the same except, all of the headers and descriptors are expander codes, for example: the header 'GEN:' expands from:

     GEN:

To:  

GEN-  Appear/General-Abn(-). VS- __. (Must include 3 of 7 vital signs__). LYMPH- (Must include 2 of 4 lymph sites__). Lymph/Neck-Abn__. Lymph/Axillae-Abn__. Lymph/Groin-Abn__. Lymph/Other-Abn__. - des__. desGEN__.__  Appear/General-Abn(-).

After you put the cursor after "GEN:" & hit the spacebar. 

Once you click and make the (-) a (+) with the descriptor 'Appear/General-Abn(-).'  It will expand from :

Appear/General-Abn(+).

To:

GEN-  Appear/General-Abn(+) with-.- Development-Abn__.- Deformities__.- Grooming-Abn__.- Communication_Aids__.- Voice_Quality-Abn__.- Body_Habitus-Abn__.- Nutrition-Abn__.- Grooming-Abn__. EXTENDED-Appear/General-Abn__.- des__. desGEN__.__ .

The purpose of these expander codes are to increase your choices related to the exam and decrease the amount of typing that you have to do.

Again, once you remove the excess or unused underlines, all that is left are the choices that you clicked on.

Reported, Denied, Noted, Not Detected, Advised, and Not Advised:

Whenever you go to print, or preview the encounter note, you will notice that the positive and negatives will be replace by text.  Depending on which field you were in will determine what the positive and negatives will be replaced with.

Subjective:  Reported (+), Denied (-).

SUBJECTIVE:

CHIEF COMPLAINT: Chest Pain reported.

HPI:

 ONSET/TIMING: Sudden reported. 4 days ago reported.

 DURATION: Acute reported.

 QUALITY/COURSE: Sharp reported.

 LOCATION: Left reported. Retrosternal reported.

 INTENSITY/SEVERITY: Severe reported.

 CONTEXT/WHEN: Similar Problems denied.

 MODIFIERS/TREATMENTS: Tylenol and Ibuprofen reported. Exertion reported. Cough reported.

Objective:  Noted (+), Not detected (-).

OBJECTIVE:

GEN: Appear/General-Abn not detected.

HEENT: Lips/Teeth/Gums-Abn not detected. Oropharynx-Abn not detected. EARS- Otoscopic-Abn not detected. Ear-Nose/Appear-Abn not detected. NOSE- Nose/Internal-Abn not detected. EYES: Conjunctiva/Lids-Abn not detected. Pupils/Irises-Abn not detected. 

NECK: Neck-Abn not detected.

LUNGS: Lung/Auscultation-Abn not detected. Respirations-Abn not detected.

HEART: Heart/Auscultation-Abn not detected. 

ABD: Abdomen-Mass/Tenderness-Abn not detected. Liver/Spleen-Abn not detected. Hernia-Abn  not detected.

BJE: Digits/Nails-Abn not detected. 

NEURO:  PSYCH: Insight/Judgement-Abn not detected. 

SKIN: Skin/Subcutaneous-Inspection-Abn not detected. 

Plan:  Advised (+), Not Advised (-).

PLAN:

Lab/Tests- CMP, UA, Cardiac Enzymes  advised.

X-rays- Repeat chest x-ray  advised in 2 days. 

You can choose not to have text replaced by the positive and negatives which is discussed in the section on Report Writer. 

Banking Your Templates

An quick & easy way to find your templates is to 'bank' them in the Template list in a certain area.  Banking can be accomplished by coming up with a simple code naming format.  For example, using your initials or placing a number in front of your template code, which will list all your templates under that particular number. 

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