Longitudinal Experience in Doctoring 3

Using an Electronic Medical Record System to Manage Chronic Disease

SOAPware

Expectation of Students

As a part of the longitudinal experience of Doctoring 3, build a complete medical record in SOAPware on 6 patients in your longitudinal panel.

Students will work with their faculty to develop a panel of 8-12 patients who have chronic diseases and select from panel of patients 6 patients that have the same chronic diseases, preferably from the following list:

•diabetes, asthma, hypertension, hyperlipidemia, CHF, osteoarthritis, depression, obesity, ADHD

If the longitudinal faculty member is not in a specialty that treats these specific diseases, the specialists can choose 6 patients with chronic illness typical of their specialty. For pediatrics, well child care of a newborn to 3 years will qualify. For OB, prenatal care for an entire pregnancy will qualify. Keep a paper list of these six patients in a secure location in the clinic and indicate on the list the fictional name you assign each patient.

  1. When you have an encounter with a patients that seem to be likely candidates for a member of your panel, create a chartin SOAPware using the demographics and document the encounter in SOAPware. After their second visit, confirm the patient as one of your 6, then populate the Summary page.The Summary page should be living document that gets updated with every subsequent visit as medications, problems, etc. change.
  2. Pick one chronic conditionper patient to track in the EMR. List this disease first in the Problems List, indicated with a *.Mine chronic patient’s chart for information pertinent to their chosen chronic illness.
  3. We will attempt to determine if this patient was one used by a student last year, and import their chart into your records so you can use the data they collected.
  4. Utilizes the health maintenance reminder systems, disease flow sheet, vital signs, etc. to manage the patient’s chronic condition.
  5. Identify the elements that will need to be in each patient’s reminder system (both disease specific and health maintenance) and set up the patient’s reminder system. Consult with your preceptor and guidelines to determine the frequency with which these should be done, then check for the dates last performed in the patient’s record.
  6. Select a pertinent Flow Sheet to use with this patient’s problem. Modify if needed. If a Flow Sheet does not exist for the problem you have selected to follow, let us know what you need on it and we will help create one. Find historic data from the patient’s chart (labs, vitals, meds, notes) to complete one column dated prior to your first visit for comparison purposes.
  7. Document each encounter with these patients by creating a new Encounter Note, updating pertinent parts of the EMR throughout the year.
  8. Remember that we will be monitoring your entries so you can not use patient identifiable data (name, birth date, address, SS number)
  9. All other chronic disease panel patients seen during longitudinal clinic will need their encounters entered into CDCS at the beginning.Do not document patients with acute problems who are not a part of your panel in CDCS. Once a patient has been identified as one you will document in the EMR, you can stop doing CDCS entries on that patient.
  10. Once per month, during the first week of each month starting in September, export your medical records for patients that you are sure will be in your pane of 6 from SOAPware (see directions) and upload the file to the SOAPware intranet site for your regional campus.

Each Visits with Patients on Panel:

  1. Create a new column on the Flow Sheet for the chosen disease and complete with findings, labs, etc for visit.
  2. Create progress notes for each visit. We will use these progress notes as evidence of continuity with the patients in your panel.
  3. Update appropriate health maintenance reminder system, medication, problems lists and so forth based on new information that has come in since last visit.
  4. Deal with specific delinquent health maintenance items with your faculty member’s supervision and approval.

Bring your computer with you to your longitudinal and use it while seeing the patient to help guide your care. You can also load M-Business desktop on your computer and use it to document in the CDCS system.

Starting and Stopping SOAPware

Close all other running programs prior to starting SOAPware as it needs all the resources on your laptop to run.

Create a New Patient Chart

To Create a new patient,

  1. File Menu
  2. Chart Rack
  3. Create Chart

HIPAA compliance measures: Due to the lack of encryption of SOAPware patient data to be stored on the student laptops, we will have to make sure that there are no patient identifiers in the medical records.

When a New chart is created, the Demographics screen comes up. Complete the form in the following manner:

  1. Last Name: Use the last name of the student.
  2. First Name: Use one letter or name starting with A for the first patient, B for the student’s second patient, C and so on.
  3. SSN: Either leave blank or put in a fake one.
  4. Chart#: There is space for 11 characters. Use this to help you identify your patient. Start with the initials of the student followed by the age of the patient, a letter that stands for race, and a letter for gender, and the number of the month and day of your first visit. Example: NBC30WF0914 This would translate to the student being NBC, the patient being a 30 year old white female whose first visit with the student was September 14th. We need to try to avoid having the same patient number assigned to two patients. That would mess up the system when the patients are synced back to the server.
  5. Date of Birth: Use January 1 of the year that the patient was actually born in. This helps the program assign the correct age to the patient for health maintenance purposes. If this is a child, it may be necessary to pick either Jan 1 or July 1, so that the age is close for the health maintenance immunizations tracking and growth charts to function correctly.
  6. Gender: pick the correct gender of the patient
  7. Primary Physician: Make sure student’s name is there.
  8. Marital Status: Select the patient’s correct marital status.

Remaining fields can be left blank or filled with made up information. Do not put the patient’s real information in these areas. Click OK when finished. You can come back later and add information to the patient’s demographics.

The new Chart will open automatically. HIPAA mandate: In the chart, no text entries should/will contain the patient’s name, real date of birth, city, or the name of the clinical faculty in whose clinic the patient is seen. Students will be cautioned to only refer to the patient as “this patient” or “This 30 yr old white female…”

SUMMARY SIDE

Second Visit with Patient on Panel

The student should obtain from the patient (and confirm with paper/clinic record)a complete history and complete the following sections in the medical recordSummary:

  • Active Problems List
    List chosen condition to track first and indicate with a *.
    Identify STABLE PROBLEMS: and UNSTABLE PROBLEMS. (note: select diagnoses from the Assessment Codes list with ICD-9 #s. See Assessment Quick Keys below.)
  • Pertinent Inactive Problems
  • Surgeries(include dates)
  • Medications List (confirm with paper/clinic record) Identify RX:, OTC: and Suppliments/herbals. Can be picked from View > Codes List > Medications. Make sure that there is an appropriate problem in the problems list for each medication listed in the medications list. (medicine reconciliation) Also identify any potential drug/drug interactions.
  • Family History Use Family History Template: quick keysFHx followed by a spacefor adults, GeriFHx for geriatrics, and type in who, relationship, at what age, etc.
  • Tobacco indicate smoking status
  • Alcohol there is a quick key for CAGE
  • Interventions These are items like immunizations, diagnostic tests, health maintenance reminders. See example in sample at right.Indicate here if an advanced directive is on file. Documents can like a living will can be scanned and added to the record under the Reports tab, Misc. Reports.
  • Social History Use quick keysochx for adults, GeriSHx for geriatric patients.

Common Assesment Quick Keys (type words on left and press space bar to unlock)

Quick Key / Description
artost / Arthritis, osteoarthritis #715.90
ast / Asthma, unspecified #493.90
bacpai / Back Pain #724.2
cad / Coronary Artery Disease #414.9
chf / Congestive Heart Failure #428.0
copd / Chronic Obstructive Pulmonary Disease #496
cysfib / Cystic Fibrosis, staging not determined #277.00
dep / Depression #311
dm2 / Diabetes Mellitus Type 2 #250.00
gerd / GERD – Esophagitis, reflux #530.10
hamig / Headache, migraine #346.90
herlos / Hearing Loss NOS #389.9
htn / Hypertension, #401.9
hypl / Hyperlipidemia #272.4
obe / Obesity #278.00
obemor / Obesity, Morbid #278.04
ost / Osteoporosis #733.00
ra / Rheumatoid Arthritis #714.0

See all Assessment Codes under View Menu, Code Lists.

ROS: Use for a complete past medical history. As review of systems changes often, not required to be a ROS. (quick key rosextend). For pediatric patients, this is a good spot for things like birth history.

Physical: Document a complete baseline physical in this section once you have had the chance to perform one. Several quick keys bring up templates for a complete physical exam: px is an extended physical exam template, GeriPE is a geriatric physical exam.

Using (+) (-) and __

The underscores are designed for easy completion of templates. You can use F12 to jump from underscore to underscore to type in findings. Also, by clicking on an underscore, it changes it to a (+) or (-). The (+) will print as either “reported” in the Subjective field or “noted” in the Objective field. The (-) will print as “denied” in the Subjective field and “ABN not detected” in the Objective field. One should replace the under lines with either text (typing) or change to a (+) or (–) if addressed in the visit.

Delete All Underlines

When the documentation is complete, to delete unused sections of the expanded quick keys, under the Edit Menu is a “Remove All Underlines” command which will delete all text between periods where an underline appears unchanged.

Entering Vital Signs

  1. Click the Vital Signstab,
  2. New Column,
  3. Enter Vital Signs for that day in the format specified.
  4. BMI is calculated from the Height and Weight of the patient, so always enter the height of the patient.
  5. Click OK.

Create a New Encounter SOAPnote

  • File Menu
  • New Encounter.
  • When the new note opens you will see a blank encounter note
  • Complete the note. There are a lot of quick keys that will make completing the note faster.

Save typing meds and problems list

  • Under Edit menu are the commands
    SOAP to Summary and Summary to SOAP. This sends the contents of the Meds List, Problems list and physical exam to the note.
  • Cut (CTRL-X), Copy (CTRL-C) and Paste (CTRL-V) work in SOAPware just like Word or PowerPoint.
  • Right click in any area to get the Codes List of quick keys for that section.
  • Do not use the comlete SOAPware templates for encounter notes. If you want to create a template, however, it is allowed for you to use your original template.

Print

Printing the note shows you how the note looks with the (+) and (-) replaced by the words either denied, reported, observed, etc. You can choose to Print Preview the note and not send it to the printer, but store it instead.

Signing the Note – Recommended to Not Sign Notes

Electronic Signatures: Once the note is complete, you have received feedback from your informatics curriculum director and made modifications to it, you can electronically sign then print the encounter. Signing the note finalizes the note and changes cannot be made to the note after you sign it. This is under the File Menu. You can leave a note open and sign it days later if you wish, even close and reopen the chart. The note will be there waiting for you in your To Do list (under File Menu) with all other documents needing signatures. So do not sign until you are through with the note. It will sit in the record unsigned.

Chart Browser

All Messages, Reports, Encounters and Flow Sheets tabs on the Summary side of the screen open the Chart Browser shown here, which organize these entries and saves them by date/time.

Chart Browser

Flow Sheets:

Flow sheets allow you to follow all the aspects of a chronic disease in one place.Here is where the patient’s disease progression can be viewed and graphed. They can pull data from different areas of the record like vital signs and health maintenance items. We will use Flow Sheets instead of the Lab Reports used last year to record patient pertinent labs.

To insert a Flow Sheet, in the

  1. Chart Browsertab
  2. Flow Sheets
  3. New
  4. Pick from list of available Flow Sheets.
  5. Pick the Chronic Disease of your patient you are choosing to follow: ADHD, Asthma, cystic fibrosis, CHF, HTN, hyperlipidemia COPD, depression, diabetes, obesity, osteoarthritis
  6. lab panels: lipids, LFT, CBC, basic metabolic panel
  7. growth charts, etc.
  8. Be patient, these are slow to come up.
  9. In the chronic disease flow sheets, if you have entered vital signs, a column will be created for you. Complete the column with findings for current visit.
  10. If no column is there, click Add Col, putting in the date of the visit, and complete with findings for current visit. Use this same flow sheet to follow the patient’s progress, adding columns with each visit.

You can select from one of the Flow Sheets for each of the diseases. There are some pediatric growth flow sheets, diabetes, hyperlipidemia, and several other chronic diseases.

Customizing Flow Sheets,

  1. ViewMenu Customization Wizards Edit Flow Sheets.
  2. To Add or modify items on an existing flow sheet,
  3. Click on the Flow Sheet you wish to edit, then click Edit
  4. Pick an item on the left that you want to remove and click on it. Click the -> button.
  5. Pick an item on the right that you want to add and click on it. Click the <- button.
  6. If the item you want to add is not on the list at the right, click Manage Items.
  7. Click New
  8. Complete the form at right. This can be a number, a pick list in which case you will need to add items to pick from at bottom, Start/Stop which gives you only those options, or just a text box to write in.
  9. Click OK
  10. Then add the new item to the existing Flow Sheet.
  11. To create a new Flow Sheet, on the Edit Flow Sheets screen
  12. Click Add
  13. Type in the name and description of the new Flow Sheet, and click
  14. Select items on the right and click the <- to add them to the new Flow Sheet
  15. Items that start with Lab are pulled from the Lab Reports section. This would require you to complete a Lab Report on each lab finding. Use lab tests that don’t start with the word Lab. Those labeled VS are pulled from the Vital Signs flow sheet.
  16. If you need items not there, follow the instructions above to add new items.

Sample Flow Sheet Items

Diabetes / Asthma / Obesity
Vitals / Vitals / Vitals
Wt / BMI / Wt
BMI / BP / BMI
BP / Pulse / BP
Pulse / RR / Pulse
RR / RR
Labs/tests / Labs/tests / Labs/tests
HbA1c / Peak Flow / Lipids
Lipids / PFT-FEV1 / Fasting Glucose
Fasting Glucose / PFT-FVC
Microalbumin / Spirometry
Meds/doses / Meds/doses / Meds/doses
Comments / Comments / Comments
Mental Health / Compliance / Diet
Diet / Exacerbations / Exercise
Foot Exam / Inhaler Use / Lifestyle
Exercise / Nebulizer Use / Mental Health
Hypoglycemic episodes? / Mental Health / Body Image
Compliance / Compliance
Sleep Apnea

Reminder System (Health Maintenance):

SOAPware will remind you every time you open the patient’s chart if they are overdue for any procedure, lab, counseling, or screening. You will need to set up the patient’s Reminder System (Health Maintenance) schedule. First decide what items you need to put in this patient’s reminder system.

To set up a patient’s health maintenance schedule, with the patient’s chart open,

  1. View Menu,
  2. Select Health Maintenance. The first time you will see the blank Health Maintenance box (right).
  3. ClickAdd
  4. Where it says View by, change from Protocols to Rules.
  5. Click on an item to add to the patient’s reminders, then click OK,
  6. Set the Frequency this item
  7. Beside the Frequency box click Add
  8. Complete the Interval Definition box. Click OK
  9. Then enter the Date Performedand click the Perform button.
  10. It should automatically tell you when the next one is due. If overdue, a Red Check will appear next to the Active Item on the left. If within the Variance of the due date, the check will be Yellow. Adjust the variance accordingly.