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SOAP / MEDICAL CHART
In This Article:
In OutSmart, every visit with a patient builds upon the last one. In some cases you are adding new information to a patient’s chart, and in other cases you are simply revisiting previous information. Whatever the particular situation, we can all agree that a client’s history is an important tool that can be used by practitioners to guide their future plan for the patient. Enter OutSmart’s Persistent Charting History function.
Example of the historical sections automatically added to a chart.
The Persistent Chart History, which I will just refer to as History for the rest of this article, is a feature of the OutSmart charting system that provides you with the entire history of your notes for that patient within every chart you create for them. Of course, there are ways that you can control the extent of this history, but the important thing to note is that you no longer have to go through previous charts to get up to date information on what a patient’s overall concerns are, what products they are on, what are the diagnoses you added to their chart during the last visit, etc. It’s all there, all the time, and if you are done with it and want to hide it, you can do so easily within the chart:
Show / Hide the chart history sections
When you see a history item in a chart, you can follow-up on that item if you want to continue to add more information. For example, you may have noted a chief concern of Infertility in the first visit for the patient. In the second visit, the patient may give you additional information about this concern. You can then follow-up with that previous chief concern, and add more notes. When taking all these follow-ups together, you begin to build the patient’s story over the course of several visits.
Some history items allow you to choose whether or not you want to add a follow-up note; in the example below, the chief concern of infertility was simply presented as a historical note. Clicking on +Note added that new chief concern section and heading to the current chart, where new notes were added.
Following up on a history item.
Other history items immediately give you the opportunity you to deal with the history by automatically adding that section into the current chart, and presenting you with options to create follow-up notes. The Diagnosis section is an example of this type of section. From one visit to the next, you will be able to ensure that the previous diagnosis is still correct, and add any relevant notes about it.
In the example below, a diagnosis section for Male Infertility was automatically added to the current chart. Quick options are to mark it as ‘Active’, ‘Resolved’, or ‘Incorrect’. This ensures that from one visit to the next, the list of active diagnoses for this patient is always kept up to date. The product list in the charts functions in much the same way, giving you the opportunity to continue or discontinue previous product recommendations.
Automatically added sections.
Some of the history sections will give you the ability to copy all the information from a previous chart into the current chart, giving you quick access to repeat treatment types with minimal effort.
In the example below, the acupuncture protocol from a previous chart can be copied over into the current cart for every patient visit. Modifications can still be made, however it is a lot easier to modify information that is already present than to continually create it from scratch every time your patient comes for their weekly acupuncture session.
Copying all acupuncture info from previous chart.
The same can be done with Injections, IV Therpy, Product recommendations and Prescriptions, Freeform sections etc.
OutSmart’s Persistent Chart History function makes it very easy to get access to all your historical information on a patient. All this history makes up the Patient Story, and this story is available to you in every chart, either for quick reference, or to use to significantly seed up your charting.
The Persistent Chart History is a feature of OutSmart that allows you to maintain a Patient Story. The Patient story is the chronological compilation of all the information you have collected and charted about the patient so far.
This charting history will show up automatically in every chart, and can have an immediate effect on the structure of your current chart, by adding product sections for active products, diagnosis sections for unresolved diagnoses, etc.
For example, if you recommended Vitamin C to a patient in their first visit, when you create a new chart during a patient’s second visit, Vitamin C will be auto-loaded as a recommendation, and you will be able to choose whether or not you want to continue or discontinue that product. This situation is what we refer to as the chart history having an ‘Active’ impact on the chart – it actually create an active section for you to deal with.
Most history sections, however, are passive and inert – they will show up in your chart, and you have the option of whether or not you want to do anything about them. For example, if you previously recorded that a patient has a Chief Concern of headaches, then this will auto load into the new chart, and if you want to add more detail you can, or if you want to mark is as resolved, then you can – but you do not have to do these things. If nothing has changed in their concern, you can just leave it as is and move on – it will not be included in your current chart for the patient.
You can hide or show the Chart History using the Chart History menu in the top toolbar.
Hiding the history will immediately hide all the history sections within the chart and the Navigator on the left – so you will then be left with a much cleaner charting space. However, it is important to note that the chart history will still have an active effect on the current chart. This means that even if you choose to hide the history, if you recommended a product in the previous chart, or made a diagnosis in the previous chart, these sections will be auto-created by the chart history to give you the ability to address them during the visit.
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