How does S.O.A.P. PLUS work?
I. Underlying assumptions, goals, and givens:
• Most potential users will have minimal, if any, typing skills
• Efficiency of use in the absence of typing skills is KEY because slow to use = no use
• Very few patients present with only a single problem
• Layout should mirror traditional patient care workflow as closely as possible
• While each practitioner’s style may be ‘unique’, there are certain commonalities that cross regional and specialty lines, ie: staff usually weighs pt before checking BP; provider usually takes entire history first, then tailors exam according to the history, then does assessment / plan summarizing all identified issues and diagnostic/treatment needs
• Recording the subjective data presents the greatest challenge
• At most offices, the progress note is initiated by support staff
• Paragraph-style trumps laundry list-style in terms of note format preference
• Templates trump transcription and voice activation in: time saved, $$ saved, shortest learning curve, greatest potential to enhance quality of care delivery
• Short learning curve is highly desirable
• Short learning curve demands highly intuitive system, minimizes things to learn/remember
• Real-time documentation during the visit is likely to be more accurate and complete than after-the-fact documentation and DOES NOT preclude eye contact
• Finishing notes patient-by-patient improves attitude and decreases burn-out
• Easy “tweak-ability” essential in order to facilitate patient-by-patient modification of a note within an encounter, and to encourage users to incorporate new ideas and updates of evidence-based guidelines into the templates themselves on an ongoing basis
And, most importantly, recognizes that:
• Real-time documentation which incorporates clinical guidelines improves patient care.
II. S.O.A.P. Plus Database features
• all office visit notes are built upon one of only three possible “starter” templates to eliminate the potential for confusion and error when staff initiate a note —
- OV: usual office visit for new complaint, chronic problem f/u, combo of both, etc.
- OVPHE: Office visit combining annual health maintenance with new complaints, f/u of chronic disease, etc.
- OVPREOP: Office visit for surgical clearance, structured to conform with documentation requirements needed to justify use of higher-reimbursement consultation codes.
- Each of these templates follows the traditional SOAP format, prompts LOS entry.
• Multiple subjective (>100) templates, robust multi-system objective templates, built-in assessment and plan Quicktext options for use in building the office note, as well as gender and age-based PHE (periodic health evaluation) templates.
• Standard global plan includes multiple embedded options for documentation of diagnostic studies ordered, treatment plan, follow-up plan, instructions, referrals, handouts given, etc. , or to reference a custom mini-plan. A work-in-progress is a set of custom mini-plans -- single problem/single diagnosis-specific, and are embedded with standard (guideline-based where possible) diagnostic and treatment options specific to that entity. Another work-in-progress is the addition of html links to handouts in the knowledge base.
• There are templates for staff to record immunizations, blood pressure checks (one for BP check done in the office – with sufficient content to justify billing a 99211 level of service – and another for readings sent in from outside), telephone triage, etc.
• There are patient instruction and education templates, bone densitometry interpretation template (which doubles as a the vehicle for informing the patient of the results and recommendations), work excuse, routine lab follow-up for monitoring statins, request for consultation, referral to the dietitian, a very efficient result letter with built-in features to facilitate future recall, etc.
• The majority of diagnoses encountered commonly in adult primary care have been entered into the Quicktext database in 3 ways: as Major Problem .MP2 format (includes place for brief note and option to change the date to other than the current), as Major Problem .MP for mat, and as Other Problem .OP format (.MP and .OP default to current date, no note). The .MP and .OP entries include the appropriate ICD.9 codes and are intended for use within the office note, facilitating both auto-update of the problem lists as well as use of the Electronic Encounter Feature. The .MP2 format is intended to facilitate the rapid initial entry of patient data into the record, which in turn facilitates standardization of entries into the major problem list by all providers in a particular practice. Because this approach is a significant time-saving strategy, it encourages the maintenance of a complete and accurate major problem list.
• All major and other problems in the Quicktext database start with either the letters MM (.MP2), or the letter M (.MP), or the letter O (.OP), followed by the common name of the problem (ie MHTN, MDM2C, MDM2UC, OEARACHE). Some problems are entered in both formats (ie MANXIETY, OANXIETY)
• Multiple assessment / comment options are included with many of the .MP and .OP pre-formatted Quicktext entries.
• Many medications used commonly in adult primary care, including OTC meds, have been entered into the Quicktext database using the .RX4 format, to facilitate ease of initial patient data entry and, in combination with use of the .DC: code, also facilitates on-the-fly update of the medication list directly from the note (ie adding OTC meds, meds prescribed by consultants)
• All subjective templates begin with the letter S followed by the common name of the chronic diagnosis or symptom (ie SHTNF/U, SHTNNEWDIAGNOSIS, SEARPAIN, etc)
• All objective templates begin with the letter O. These templates are duplicated in the template database and in the Quicktext database.
• All templates make extensive use of the PP dot codes and letter codes (which import and export VS data, HM data, med list data, major problems, and laboratory data to and fromnotes / letters and those individual data tables), and of labels markers as ‘stop/change points’, because these features drive:
-efficiency of use (again, difficult/slow to use = won’t use)
-consistency, completeness, accuracy, searchability, and ultimately usefulness of problem lists, med lists, and health maintenance in facilitating delivery, tracking, evaluation and maximization of performance to achieve the goal of providing the highest possible quality of patient care.
III. Building a note (example of actual template, and template-generated note, follows)
• Staff starts the note using the appropriate template for the type of visit (**The ‘starter’ templates pull in last vital signs, HM data, med list, allergies, major problems)
• Staff enters vital sign data into the note and partial saves, or:
**Depending on practice style, the template structure could certainly also be used to have staff enter a chief complaint, and / or a subjective template with collection and entry of some or all of the information in the template prior to partial-saving the note
• Provider reopens the note and continues the visit, initiating (or completing) the appropriate subjective template(s) – sequentially dropping in as many as needed to document the history of all of the patient’s complaints and / or chronic medical problems addressed in the visit
• Provider examines the patient, and uses one of several objective template options available to document the exam (ie. OMISC – a head-to-toe bank of embedded options for normal or abnormal exam findings for each organ system; OHTLNGABDT (objective for a heart / lung / abdominal exam preformatted to meet criteria for a level 4 –DETAILED (ie 99214 or 99204) exam, etc)
• Under A/P (assessment/plan), Provider enters the major or other problems evaluated from the pre-formatted list in the Quicktext database, or – if desired preformatted problem is not found there – from the Problem/Diagnosis Database in Practice Partner. If this particular diagnosis is likely to come up again, one can add it right then to the Quicktext database (using the “Task” button at the top of the program), or jot it down to be added at the end of the day.
• Using the embedded options under the standard plan, or a custom mini-plan template, the provider documents all the diagnostic, treatment, follow-up, etc., portions of the plan, along with the level of service (NOTE: WHILE S.O.A.P. PLUS facilitates documentation to support highest appropriate level of service coding, and provides some coding tips, it does NOT actually calculate the level of service for the visit).
• Templates for patient education, consult requests, informational or result letters, etc., may be entered and printed or faxed from the appropriate chart section.
EXAMPLE OF S.O.A.P. PLUS template and template-generated note
1) "STARTER" TEMPLATE FOR OFFICE NOTE (AS IT APPEARS IN MAINTENANCE BEFORE INSERTED INTO NOTE):
2) TYPICAL TEMPLATE-GENERATED OFFICE VISIT NOTE USING S.O.A.P. PLUS FORMAT
Templates inserted into basic office visit starter template: Searpain; SHTNf/ubrief; Sasthmaf/ubrief
Actual typing needed to generate note: NONE, other than insertion of # of days since onset of sx, temperature, and BP range.