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The Diagnosis medical record category still exists for coding purposes. This is separated from the Diagnosis Problems within the SOAP documents. Diagnosis have also had improvements in 5.0 and you can learn more about it at Episode Diagnosis in 5.0 . |
Episode SOAPs
With the improvements to problems and SOAPs in 5.0, each problem can now be assigned to have its own AP independent of a holistic SO that can be applied to all problems for the patient on the same visit.
This method will reduce the amount of duplicate data entry needed to perform a full SOAP on a patient that has multiple problems.
Start SOAPing a problem within a Document
Add any document that has SOAP elements added to perform a SOAP.
If the Problem element appears at the top of the document, all four SOAP elements will be applied to each problem.
If the Problem element appears in between the SOAP elements, only the elements that appear after the problem element will be repeated for each problem. Those that appear before will be considered the same for all problems within the document.
When the document is saved without any text, it appears collapsed like this:
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When the document is open for editing, you can add the text elements to each portion of the SOAP before selection the problem, as appropriate.
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If the A and P elements are set to display before adding a problem, then the first problem that is added will be considered to be the problem that these elements are applied to.
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As part of the improvements in 5.0, all document categories now have a basic default document template, including SOAPs. If your hospital unit has not made their own custom SOAP document, you can use the default template to add problems and SOAPs with minimal elements. You can also access all other documents within the hospital by viewing Other Options.  |
Manage SOAPs: Submit for Review, Comments, Approvals
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