Native SOAP note feature add

juggernautsei wrote on Tuesday, October 25, 2016:

Been working in and around the soap note for a while and decided to update it a little.

Completed the feature to populate it with the previous note if there is one.

My question is should this be a global feature that has to be “turned on”? Then I’ll submit for review.

The next thing to add is the ability to populate the field with common data like the medication and vitals.

Yes, I know that the nations note does all this but there are people that don’t really want to use the nations notes.

So, that is why it is being added to the native soap note.

cverk wrote on Tuesday, October 25, 2016:

I like the idea of populating common data to an encounter note. As you see a patient we update things like history, problem lists, medication lists,prescriptions, maybe give a flu shot, etc. These things are not static and may be changed at the next visit so your current lists may not reflect anymore the original data from those lists. Not all encounters require all those things but it would be nice to perhaps have buttons to populate those various tables into your current days note when they are relevant. This would also be helpful in documenting your level of coding as coding guidelines are more about checking all those boxes than about how much skill that encounter required. I have commonly used a copy and paste from a generated report particularly on physical exams to bring information from the tops screens into a bottom note, but that is not an elegant solution

mdsupport wrote on Tuesday, October 25, 2016:

Any change you do the existing soap form consisting of 4 text areas will have to be considered as an improvement. Here are couple of observations based on our experience:

Copy previous note
We implemented this feature sometime ago. The feedback from clinicians is mixed. It is great when dealing with patients in steady state / chronic issues. This feature now allows verbose notes with minimal effort but puts practice at the risk of audit. For patients with changing content, instead of copy+paste users do lot of select+delete+type new text.

As a result, we plan to make the application issue centric. Each version of issue record will be “frozen” when an encounter that last addressed it is signed off. This allows “note” to be created using a note-template.

populate the field with common data
Problem with this is there is no longer single version of truth which should be maintained at all costs.

Nation Note
Must agree that clinicians do not like current interface. May be implementing latest version of ckeditor which allows inline editing and typeahead should be added to the wishlist.

juggernautsei wrote on Thursday, October 27, 2016:

Thanks for the input. It is really helpful.