Visit information can be recorded in the traditional SOAP format with a digital twist.
The Subjective contains the patient’s narrative, and the review of systems. There is a list to check a review of systems, with 16 different areas, from respiratory to neurologic, each containing a drop-down menu of choices, to which you can add anything else you want.
The Objective contains the vital signs, physical findings, and lab work. While you record these for any given visit, each of these is also stored for separate viewing and retrieval. For example, you can look at all the patient’s vital signs from many visits all in one place.
The Assessment includes investigations, diagnosis, and progress report areas. You can search for diagnoses and you will get the correct ICDM9 code for the diagnosis.
The Plan area includes things to-do, treatment plans, procedures, prescriptions, immunizations, disposition, and follow up.
To-do items can be listed by who should do them and when.
For example, a nursing assistant could check the patient’s blood pressure at every visit. Treatment plan includes short and long-term goals.
Procedures can be selected from a drop-down list which includes ICDM codes. Prescriptions can be selected from a drop-down list, as can common instructions, such as bid for 7 days.
You can customize this list, as you do with allergens. Just click on modules, pick medications on the left,
and enter whatever medications you want added to the list.
You can print out the prescription. If you dispense drugs from your office, there is also a place to enter what you dispensed.
Immunizations can be recorded or selected from a drop-down list.
There is a place for lot number and other information. Disposition includes when you expect to see
the patient back, or if the patient was sent somewhere else, like the hospital. Follow-up plan leaves an area for you to describe your plans for the patient.
Below this is a list for health forms. You can access the review of systems form from this area, as well as other forms.
There is a place to attach images, like X-rays, or other documents.
It is in this area that you can tag the patient for later retrieval of data, with a tag for diagnosis or occupation or anything else you might want to access.
Billing information includes charges, and payments. From this box you can generate receipts. You then have the print visit option. You can select to print some or all of the information you recorded.
When you click on a patient’s record and pick a date, you will see the type of visit, the diagnosis, the charges and payments, all the data you recorded in SOAP format, plus the health forms.
You can access that same information in other ways. If you look at the Summaries area, you can select patient narratives,
for example, and every patient narrative from each visit will be displayed.
Or you can look at physical findings by date, or prescriptions, any of the information categories you entered during the visit.
In the patient forms area, you can enter information onto forms such as illustrations of injuries, or letters of referral.
You can add any forms you already use in your practice.
Finally, you can print patient records. You will see that there are different ways to do the same thing. You can print the patient’s record from the print area or the visit area, for example.