BEFORE YOU START
BUILD YOUR TEAM
GET READY FOR LAUNCH
ADVANCED SCHEDULING WORKFLOWS
EXPLORE SMARTFORM QUESTIONNAIRES
EXPLORE REPORTING TOOLS
EXPLORE INVENTORY MANAGEMENT
RAPID CHARTING WORKFLOWS
ADVANCED DISPENSARY WORKFLOWS
TASK LIST MANAGEMENT
CUSTOMIZE YOUR OUTSMART EXPERIENCE
DOCUMENTS / FAX
SOAP / MEDICAL CHART
In This Article:
A Medical Chart, or SOAP Chart, in OutSmart are the notes taken during a single encounter with a patient. A chart would be created every time your patient comes to see you. All of these charts are stored in the Patient Workspace, which is like the patient’s folder in your clinic. In some professions, a Medical chart may refer to your patient’s entire history, however in OutSmart, that is not the case. A Chart refers only to the notes taken during a single encounter with the patient.
A Medical chart, or SOAP chart, can be created in OutSmart from a number of different places. A chart can be created from:
You can initiate the creation of a chart from the Event Editor in the calendar. This is useful if you would like to move directly from your calendar to the charting interface. It also helps to save a step when you create the chart because the system will not need to ask you which visit type is involved. Since you are creating the chart from the Calendar Event Editor, then the system already knows the visit type involved.
Creating a SOAP chart from the Daily Schedule Card on the Dashboard is the easier and simplest way to create a chart. The Daily Schedule Card is responsible for displaying all your appointments for the day, so it’s the logical place to go when checking your next appointments, and initiating the creation of a SOAP chart.
If you prefer to get quickly caught up on your client’s file and notes before starting your chart, the Client Workspace is a good place to go. Once you review your notes, you can create a new chart for the patient right from here. Remember that in OutSmart, you are creating a new SOAP chart for every visit.
The OutSmart charting interface puts all the most important tools and pertinent information right in front of you. Your entire chart is managed from a single screen, and an index is automatically created as you go in order to help you navigate your chart and move from one section to another easily.
The Chart Properties record the subject patient, the visit type, and the date and time of the visit. All information in the chart properties can be changed, but note that these are also part of the audit trail, and every change is recorded.
You can edit the Chart Properties simply by clicking on them. This will bring up the Chart Configuration panel. The Chart Configuration panel will also show up anytime critical information about the chart is missing. For example, if you create a chart from the Patient Workspace or the SmartCharts page, a Chart Configuration panel will appear asking you to specify the type of visit this will be. If you create a chart from the Calendar or Daily Schedule card, then the Chart Configuration panel will not show up, because the system will already know the type of visit involved.
The Chart Index is a great tool to keep you anchored when charting. It will automatically update with information about all the sections you add into the chart. As you get familiar with charting, you will start using PRO sections which give you added functionality. Since the entire charting experience takes place on a single screen, the Chart Index becomes an invaluable tool to navigate your chart to quickly add information to various sections.
The Chart Index can also be used to re-order the sections of your chart. Just drag and drop any title or section in the Chart Index and drop it into a new order. This will automatically update both the index, and the chart itself.
The toolbar at the top of Medical chart connects you to other patient data, adjusts your charting view, and allows you to save and print.
The main toolbar of the SOAP charting system gives you access to a variety of functions:
This Chart History button will give you access to show of hide the Persistent Chart History sections of the SOAP chart.
The Print Treatment Plan button will generate a Patient Treatment Plan which you can then print to paper or to PDF.
The Print Chart button will generate a Full Chart print view, which you can then print to paper or to PDF.
The Save button will save a draft of your chart, and create an individual backup, in case you need to restore data at a later date. Note that for audit purposes, the data you enter into your chart is time-stamped every 5 minutes.
The Lock button will digitally sign your chart. You can still unlock the chart and edit as needed, the when you click on the lock button it essentially means that you have signed your chart, and it is a legal document now.
The Additional Actions button opens up a list of other actions you can take, which includes viewing submitted SmartForms, previous charts, going to the Client Workspace, creating a new chart for the client, or deleting the current chart. Note that charts are never permanently deleted.
At the far right of the toolbar, you will also be able to see the last time the chart was saved. The chart will auto-save every 2 minutes.
The Chart Notes area of the charting interface is where you put your notes. Depending on whether you are using Basic Charting or Pro Charting, and your own personal charting preferences, the Chart Notes area will vary in terms of what is presented on screen. But in the end, this area of the interface is where all your medical notes will go. You can learn more about the Basic Charting sections here. When you are comfortable with the basic sections, you can then move on to PRO Charting.
Clicking on the ‘lock’ button at the top of the Charting Interface is essentially the same as signing your chart. It stamps the chart with a date and time for the signature, takes you out of the Charting Interface and back to your SmartCharts general page. The chart is then also listed as locked in your chart list. You can still unlock the chart if you want to make additions, however remember that the audit trail for your chart will reflect that changes were made after the chart was locked.
To unlock your chart, simply click on the red button in your chart list, and this will unlock the chart and allow you to continue editing.
There are several reasons why you might want to delete a SOAP chart, or any kind of medical chart you’ve created in OutSmart : a patient does not show up to the visit, you accidentally create a chart for the wrong person, etc. Just keep in mind that our system never actually deletes anything – all deleted charts are archived in our database, and you can even restore them at a later date if they were deleted by accident. Because of this, it is important to make sure that you delete charts in a manner that is consistent with the legal requirements of your profession.
Let’s say you created a SOAP chart for a patient and entered some preliminary information, but the patient did not show up for the visit. You can either keep the chart there until the patient does show up and then continue the cart, or you may want to delete it. If you are deleting a chart with existing information, it’s important to make a note in the chart about why you are deleting the chart. Making a quick note like “Patient did not show up, deleting chart” is enough. Then you can go ahead and delete the chart.
If you are simply deleting a chart created in error, and there is no information entered into it, then you do not need to leave a note, just delete the chart.
To delete the chart, you must open the chart in the Chart Editor, which is the page you go to when you are actively adding information to the chart. You can access the editor by opening the chart from a Chart List. Chart lists are available in the Patient Workspace or the Smart Charts page. When you locate the chart you want to delete, open it in the editor by clicking on the Continue Editing Chart button in the right-most Actions column of the chart list. This will open the editor. Then click on the More Actions icon in the Top Toolbar, and select Delete Chart.
In the Basic Charting system, a Patient Treatment Plan is easily created by simply typing in your treatment plan in the Plan Freeform section of your chart. Everything you enter into the Plan Freeform section will show up on the Patient Treatment Plan. So the steps to creating a Patient Treatment Plan when using Basic Charting are:
This will generate a printable treatment plan for your patience which you can print to paper or save to PDF.
There are a few different locations from where you can print your Charts or Treatment Plans:
The Chart Editor is what is on screen when you are creating the chart. This where you are actually typing in the patient’s medical information. When you are on this screen, you can access the print view of this chart by clicking on one of the ‘print’ icons in the Top Toolbar of the chart.
Chart lists are displayed in various areas, like the Smart Charts page, the Patient Workspace, etc. When you want to print a chart that you are seeing in a chart list, click on the icon ‘Full Chart’ or the icon ‘Patient Treatment Plan’ to open up the print view.
Once you have the print view open through one of the above methods, you can switch between the Patient Treatment Plan or the Full Chart by clicking the orange View Patient Plan or View Full Chart button at the top.
To print the chart you are viewing, click on the blue Print Chart button at the top right. when you do this, it will open the Chrome Print Window, which will give you your printer options.
To print your Patient Treatment Plan, click on the Print Treatment Plan button at the top of the Charting Interface. This will open up a print view of your treatment plan. You can then click on the Print This Page button at the top right of the treatment plan, to open up the browsers printing dialog box.
From there, you can choose to print to a printer, or you can also print to PDF. Printing to PDF will create a PDF file that you can save on your computer.