Back to: Charting a SOAP Note (Old)
In this Lesson, we’ll cover the following topics;
- Creating an Encounter from the Dashboard appointment
- Accessing existing encounters via PATIENT >> Encounters
Then, we will discuss the areas that Clinical Staff are most likely responsible for completing at each visit.
- Standard Encounter Visit tabs:
- How to Chart A Note
Creating an Encounter from the Dashboard appointment
When you log into the system, you will be directed to your dashboard. Any appointments for the day will be visible here.
With your mouse, hover over the patient’s name. There, you will see a pop-out box that allows the user to “Start Encounter“, go to the patient’s “Chart” or “Demographics“.
If it’s necessary to step away, and then come back to the note later, you may still access the note from the dashboard. Hover over the patient’s name, and if the encounter has already been created, you will now see that “Start Encounter” has been replaced by “Resume Encounter“.
Accessing an Existing Encounter
Another quick and easy way to search for an Encounter is from the Menu Bar. Go to “Patients>>Encounters“. This is the best way to find an encounter with a date of service that is older than the current day.
From here, you will be presented with a list of all encounters.
You may search for the encounter by putting the patient’s name in the “Find Patient” box, or search using additional criteria available by checking the “Advanced” box.
Enter your criteria and a list of matching records will be returned.
Once you’ve found the patient/encounter you’re looking for, simply click on the line and you will be redirected to the Encounter.
Standard Encounter Visit Tabs
- SUMMARY – The Summary Tab provides quick access to ALL patient information; Prior Visits, Completed forms, Allergies, Problem List, Medications, Orders and Health Maintenance programs. While you may access ALL prior information, the Summary page will display the most recent/prior ten (10) of every sub-section. (e.g. most recent 10 visits…).
- CC – Chief Complaint / Common Complaint
- HX – Patient History (Medical, Surgical, Social, Family) is tied directly to the patient chart.
- HPI – History of Present Illness/Injury
- ROS – Review of Systems may be completed by the patient within the Patient Portal and it will be automatically be imported into the note.
- Vitals – Record or update the patents’ vitals. Depending upon your practice, you may also have custom vitals
- PE – Physical Exam
- Meds & Allergies – This is also available to the patient to complete within the Patient Portal and is also tied directly to the patient chart.
- POC – Point of Care – This section is only to be used when providing billable services, within the confines of the practice (practice is reimbursed directly by the payers).
- Results – this is where lab results are stored. There are 3 variations; “Point of Care” which are completed and billable from within the practice. “Outside Labs” this is where results from outside labs (i.e. mProbe, Quest, LabCorp, etc..) are stored and available for review. “Documents” are where lab results are stored from facilities which may not have electronic interface capabilities, have faxed results, or old results have been scanned and stored in the patient file.
- Assessment – This is where you will be able to begin diagnosing your patients, and selecting the appropriate diagnosis codes.
- Plan – This is where you where you will create your plan of action/treatment plan for your patient.
- Superbill – This is where you complete the note and submit it for billing (if applicable)
Patient Summary
This is the very first tab you should see when opening a note. This page will provide you with quick information about the patient, and their chart. You will see their Name, Demographic data, any clinical alerts, as well as their Forms, Past Visits, Past Vitals, Allergies, Meds and so on. While you will have quick access to ALL information in each area, the system will display the most recent ten (10) of anything.
IMPORT FEATURE “Patient Forms”. If the patient has completed an online form (located within the Patient Portal, it will be displayed in this section. You will see an “IMPORT” button beside each form.
If you’d like to download the information captured from that particular form, you would press the “Import” button and all the contents of that particular form would be placed into the Top of the HPI tab. (see example)
IMPORTING PRIOR NOTES:
The system also allows you to import information from a prior visit/note. This may save you time, as you will not have to retype the information. Instead, you may choose to simply update the information. To import this, select the visit you wish to import by pressing the “IMPORT” button. When you do this, a dialog box will appear which displays all of the tabs available from the prior visit, which may be selected for import. It’s important to know that you will not be able to import information from a prior visit that remains “Open“. A note must first be “Closed” before you may import information from that visit note.
If you’re unsure of the information that you wish to import, you may first review the prior note without leaving the current encounter. To do this, press the “Details” button and a pop-out will appear, which will allow the user to review the prior visit information.
You may quickly tell which prior encounters have been “Closed” as they will be the ones that are NOT highlighted in “Yellow“.
You may NOT import information from a prior visit note that has not been closed and locked. Should you attempt to import data from an Open visit, you will see the following error message;
NOTE: All patient demographic information is already part of the note. It is not necessary to repeat demographic data when charting a note.
Beginning The Note
Chief Complaint
You may notice, on the right-hand side of the screen, that some “Chief Complaints” may already exist. The first “Complaint” is usually what was entered as the “type” of visit (example – OFFICE VISIT). It is OKAY to delete this (with your mouse, click on the red “X” beside the text to delete it), as it is often not something that you would actually chart on.
You may add additional “Complaints” by entering them in the “Search” box. Once the complaint has been typed/dictated within the box, select “ADD”, and it will be added to the “Chief Complaint” list on the right- hand side. Repeat the process until all appropriate complaints have been added.
The note is defaulted to the “Text Search“, however, you may also add Common Complaints by using the “Drill Down” button, which will open up a list of Common Complaints which you may select from.
Hx Source – You may also list the source of the information being provided from the selecting the appropriate item dropdown list.
At the bottom of the screen you will see two boxes. The first is the “Patient’s Previous Complaint(s)”. This box keeps track of all the complaint listed on prior visits.
This allows the user to quickly select a prior complaint if necessary.
Next you will see a list of Common Complaint Macros
The “Common Complaint Macros” are located in your “Preference” tab of the menu bar (Preferences>>Favorite Lists>>Common Complaints), and will pre load information associated with the macro you’ve created, into the HPI area. Macros are covered in a different module.
HPI – History of Present Illness/Injury
This tab allows you to begin addressing each of the individual Complaints that have been selected, or combine them all into a single issue.
NOTE: If you choose “No” it will combine ALL complaints into the first one present. If you are using a Macro as your first complaint, then ALL other complaints may be subject to the information present.
To begin reporting on a particular complaint, choose the “(Click to Add Free Text)” button
and the dialog box will appear. From here, you may dictate your note in one of several methods.
FREE TEXT
When the dialog box opens you may begin typing any text you wish, or edit the information already listed within the area. (REMEMBER, any “Form” that you imported will also be listed in this area)
MACROS
Macros are predetermined text associated with a shortcut name. They, like your “Common Complaint Macros” are located in your Preferences section (Preferences>>Favorite Lists>>Macros)
To deploy a Macro, use the dropdown box located in the lower right corner of the dialog box you wish to insert the macro into.
Once you’ve selected the macro, the text associated with that particular macro will appear in the dialog box.
As you become more and more familiar with the text associated with each shortcut that you’ve created, you may also deploy a macro by typing a “?” in the dialog box, which will open up a list of macros as well. The question mark “?” is also known as a “Wildcard” and will deploy the macro library anytime you use it in a free text area.
DRAGON VOICE DICTATION
OneTouch has Dragon Medical360 Dictation software integrated into it’s software. This feature allows the user to dictate the note audibly using whatever device they’re charting the note with, assuming the device has a built-in microphone. (Dragon Voice is an add-on feature and requires a paid subscription).
NOTE – You must activate Dragon (If applicable) by pressing the Microphone button, and Click it again when you’re done dictating. Once you’ve completed your dictation, select “OK” and move on to the next condition. If there are no more conditions move on to the next tab.
Can you use other dictation software to dictate a note inside OneTouch?
This is a question not easily answered. We’ve seen providers use “Siri“, as well as their own personal Dragon Medical license to dictate notes within OneTouch. In some cases, we’ve seen practices integrate a handheld microphone, which is used with a dictation software, to also chart a note. However, none of those options are supported by OneTouch and in cases like this, it usually requires some technical support from the maker of the microphone and/or dictation software to set it up properly. In cases where this doesn’t work, you may wish to consider using the Dragon Voice feature that OneTouch offers.
When you are done entering the text in the box you’re working in, make sure you hit the “OK” button, located in the lower left-hand corner, to save your work.
How to use Dragon Medical Voice Dictation (if you have the add on)
HX – Medical History
This section is tied directly to the patient’s chart. Here you will see any medical history that they have listed (Medical, Surgical, Social, and Family). If an additional issue is discovered, or disclosed by the patient, and you’d like to add that to their Medical History, simply select the appropriate sub-section (Medical, Surgical, Social or Family) and hit the “Add New” button located at the bottom of the page.
For new patients, this information may be “Patient Reported” via the Patient Portal. You may find this area blank, as no prior information may have been imported. If you wish to add to this file you may do so by selecting the appropriate history you wish to add (Medical History, Surgical History, Social History, Family History) and then hit “Add New”.
Here you will be able to add any information you discover.
When you’ve completed with the information, hit the “Add” button located at the bottom of the page to save the new information.
In the diagnosis box, you may enter either the ICD10 code or search by condition, and select the appropriate code. Select whether the condition is “Active” and add any comments you wish. Once finished, hit “ADD”.
Repeat the process until you are satisfied with the history.
NOTE: It is important NOT to dictate your entire diagnosis into the Diagnosis search bar. Your goal is to put in only the information necessary for the system to access the ICD10 code.
You may also remove information by checking the box next to the item you’d like to remove and hit the “Delete Selected” button located at the bottom of the page.
Meds & Allergies
This tab is also tied directly to the patient’s chart and, along with the medical history is largely patient reported. Review any current allergies and/or medications here.
Allergies are located at the top of the page.
Again, should you learn through the course of the visit that there are allergies that have not been listed, you may easily add them using the following methods. To add an Allergy, select the type of allergy from the drop-down menu. Next, in the box below that, type in what the allergen is, then the reaction (i.e. Drug – Aspirin. Reaction – Hives). Press “Save” when finished.
First, select the type of allergy it is from the dropdown menu located in the upper left corner.
Then in the two blank boxes below the field, complete the information and “Save“
To remove an item, simply click on the “X” located next to it.
To change the status of an item, click on the item status and select the appropriate indicator from the list of available options.
Medications
These are located in the second half of the page.
If you’d like to have ALL medications displayed, simply check the box located at the upper right of the list.
To update the status of a particular prescription, simply click on the “Status” and select from the list of available options.
At the bottom of the page you may see additional information related to any allergy.
ROS – Review of Systems
The fifth tab in the Encounter, this is typically completed by the patient during intake. The template body systems are defaulted to “Reviewed/Negative” and will report specific conditions which are present/active.
If this is the first time seeing this patient, and the Practice Administrator has chosen to allow the patients to complete a ROS from within the Patient Portal, the information will be imported into the encounter. If however, that is not the case, then the Clinical User may complete the information if necessary.
Depending upon the practice, there may be multiple ROS templates available for different types of visits. To change the template, look in the upper left corner of the page and simply press “change“, and select the appropriate template from the list of templates within your practices’ template library.
Vitals
These should be completed by the nurse or medical assistant prior to being seen by the physician. It’s the 6th tab, but may be easily moved in the order of the note by simply dragging and dropping the tab in the order you’d like.
Adding height and weight will automatically calculate the patient’s BMI
Graphs
The “Graph” button located beside each vital will provide you with a snapshot based on the prior 10 visits.
Pediatric Graphs
If the patient is younger than 18 years (as indicated in their DOB within their chart), there will be pediatric graphs that will automatically load into the vitals area.
You will notice several additional tabs and measures are now present, which include “Weight-Age Chart“, “Stature-Age Chart“, “Weight-Stature Chart“, “BMI Age Chart“, which are all located in the upper right of the Vitals area. On the left side you will see “Head Circ“, “Waist“, “Hip” and “Last Menstrual Cycle” if the patient is female.
Using the graphs at the top, you will be able to quickly see how the child is developing based upon national standards.
Growth charts
To print a growth chart for a patient or parent, you will need to “Print Screen” or Save an image to your desktop.
PE – Physical Exam
This section is rarely ever completed by clinical support staff, however if your clinical staff does complete the Physical Exam, they may do so here.
Under “General/Constitutional” select (Click to Add Comment) and begin charting your note. (NOTE: As you generally chart an entire exam in one uninterrupted dictation, it is recommended that your scribe cut/paste your notes into the appropriate body systems prior to closing/posting the note).
To begin, click on the Body System you wish to work on and check the appropriate Exam Elements and select the appropriate observation.
(+) would indicate the the patient is positive for the condition. (-) would indicate a negative finding, while (NC) would indicate “No Change“. You may occasionally see blank text areas. These are “Free Text” observations, and allow the provider to write in their own observations.
POC – Point of Care
This contains seven (7) sub sections, which also mirror some of the Plan sections of the Encounter note. Lab, Radiology, Procedures, Immunizations, Injections, Meds and Supplies.
It’s important to know the difference between the POC and the Plan Section. The POC area is for ANY service provided by the practice or provider for which compensation may be received. The Plan section is for any service the practice outsources (i.e. LabCorp, or Hospital Radiology Dept.).
More than likely clinical staff may not order items in this area, however, they may provide the services. For example the provider may have ordered a Botox injection as a procedure. If the Clinical Staff is to perform the injection they may complete the procedure in this section.
Labs
This section will list any in-house labs that the practice or provider may conduct. The practice administrator may categorize labs, or leave them all under a single category.
To order a lab, simply check the box to the right of the lab you wish to use and press the down arrow next to the lab, which will then open it up for use.
Here, the provider, or their staff may fill in the additional information (lab facility, LOINC Code).
And then complete the rest of the information in the test.
Once the test has been completed, you must change the “Status” from “Open” to “Done“.
Radiology
Radiology operates in the same manner. These are any radiology services that are performed by the practice or providers in-house.
For example, when ordering an x-ray, the provider may select the number of views.
Procedures would again be anything that is conducted in-house at the practice or performed directly by the provider, or their staff.
When the provider selects a procedure, they may make any initial notes and leave instruction(s) for the individual(s) who may be completing the procedure.
A diagnosis (reason) must be selected for the purpose of the procedure, as is true in most tabs in this section.
Once the procedure has been completed, the staff member would change the status from “Open” to “Done“.
Additionally, the staff member could provide additional documentation in the comment section provided.
Using a Form in the POC
The system has a unique feature in that it allows for a Form to be used inside the Procedures area of a Note. When an online form is associated with a specific procedure, the form will automatically populate when the provider orders the procedure.
An example may be a provider ordering an injury report. The technician performing the procedure would then be able to notate their findings.
Once it’s completed the provider will see it in the POC area of the Visit Summary.
Immunizations – Would be any type of immunization conducted in-house.
When a specific immunization is selected, the user must then provide the information necessary to complete the form, which would include information available on the specific medication being used.
Injections – are popular among many practices. For example, here we may typically see B12 shots, Cortisone, or Infusion therapy medications.
Meds – would be any medications administered or dispensed from within the practice.
Supplies – could be used for a number of items. Durable Medical Equipment, or other supplies that may either need to be tracked, or billed as a result of services provided (i.e. wound wrap, lidocaine patch, crutches, cPap machine)
Results
This is where lab results will be stored for review. There are three (3) sub tabs; Point of Care, Outside Labs and Documents.
Point of Care are lab results for any labs performed in-house.
Outside labs would be results sent back to the practice (i.e. LabCorp).
Documents would be results that have been faxed to the practice and were saved as a PDF or image file.
Assessment
This section is where the patient is diagnosed.
The first box is a “Search” bar. From here you may search either by condition and/or by ICD10 code. Once you have found the appropriate diagnosis, select the “Highlighted Diagnosis” and press “Add”. This will move the diagnosis to the bottom of the screen.
The next box below the search bar is the “Favorites” bar. A list of favorite diagnosis has been created for you (Preferences>>Favorite Lists>>Medical Dx), and are in alphabetical order. You may use this to select your diagnosis. When you have found the diagnosis you wish to use, simply click the “+”, using your mouse, and the diagnosis will be added to the bottom of the screen.
The “Chief Complaint(s)” box will outline why you’re seeing this patient today.
The third box “Past Diagnosis(s)” will display all the prior diagnosis’s you’ve assigned this patient in the past. You may reuse the diagnosis and select it by pressing the “+” symbol with your mouse.
The “Problem list” is any condition which may be reportable.
Plan Section
There must be at least one (1) diagnosis code in the Assessment, in order to open up your “PLAN” section.
You will notice the “Assessment(s)” listed to the left of your screen. The “Highlighted” diagnosis is the one that you will be creating a Plan for. This is also indicated under the main part of the screen (Plan for….).
In order to add text to the plan select the “Click to Add Text” link in the dialog box and begin typing, or dictating the plan. Once finished, hit “Ok”.
If you need to send an order to an outside lab (i.e. Quest, LabCorp), you may do so with the “Labs” button. Repeat the process for Radiology, and Procedures.
Mandatory Fields when ordering electronic labs.
It’s important to note that those offices who choose to have electronic lab interfaces may experience difficulties if certain information is missing from the patient chart.
When ordering labs electronically, it is mandatory that insurance information and guarantor information be completed within the patient chart, otherwise the provider will be unable to submit the lab order.
The “Insurance” and “Guarantor” tabs are located in the “General Information” area of the patient chart.
Writing Prescriptions
using the Rx button, open the Rx Builder and complete the form.
Once completed, you may submit the Scrip to the pharmacy electronically by hitting the “Submit” button at the bottom of the screen.
You may also notate a “Follow Up” visit by moving your cursor to the appropriate boxes and indicating when you’d like the patient to return for a follow up.
Superbill
Once you’ve completed your plan, move to the Superbill tab. First select your service level from the drop-down menu.
Next, select the “Advanced” option to the right of the Service Level box. Here, you may select additional service level codes when appropriate. The system keeps track of the time that an encounter/note was opened, until the time it is “Closed” so, YOU MAY NEED TO ADJUST THE TIME TO CORRESPOND TO THE BILLING SERVICE LEVEL. To do this, simply move your cursor to the appropriate box and adjust the time. To collapse the “Advanced” box, simply “uncheck” the “Advanced” box again.
Scroll to the bottom of the note to the page. Here you may put any additional comments if needed.
Clinical Staff will most likely need to forward the not to the “Supervising Provider” which may be done by selecting the appropriate provider from the dropdown list.
Or, forward the visit summary to the supervising/primary provider for review.
Which may be done by selecting the appropriate provider from the dropdown list and then hitting “Send“.
The visit summary will then appear in their quick list located on their dashboard.
Once the note is completed, the provider will insert their PIN in the appropriate box and “Close” or “Close + Post Charges” (if using OneTouch PM/Billing Software).
The note is now locked and you may go to the next note.
How To Chart A Note
End of Lesson
