...
| Panel |
|---|
| Panel | ||||||||
|---|---|---|---|---|---|---|---|---|
| ||||||||
Episode Problems and SOAPs |
The Problem List and SOAPs section allows you to add in episode problems, which can then be linked to the patient's master problem list. It also allows you to complete a SOAP for the episode regarding the identified episode problems.
Add A Problem
Click on Add Problem to open up the Episode Problem list.
Add A New Problem
Depending on your hospital's settings, the problems available may be restricted to a pre-created list visible in the drop down, or you may be allowed to enter problems via free text.
Move an Existing Problem from the Master Problem List
Existing problems appear on the left. If the problem is still present during the current episode, click on the Arrow to bring it over to the Episode Problem list.
Click on the save button at the bottom of this window to add the new problems to the episode.
Add SOAPs to an Episode
Once you have added Episode Problems or marked any existing Master Problems as active for the current episode, you can begin to SOAP the problem.
The SOAPs are entered and verified independently. As this is intended to be one of the primary teaching tools for VetView, the SOAPs can be approved, rejected, or marked for revision by a clinician.
Once the SOAP components are saved, additional comments can be appended. SOAPs support Rich Text Format, so you can use different font colors and sizes when appropriate.
Merge Problems as part of Differential Diagnosis
If problems have been identified to be related (e.g. symptoms of the same underlying disease) you can Merge the problems within the episode, or under the Master Problem list.
Select the problem to which the existing problem will be merged.
The problem will then appear on the Episode Problem list and Master Problem list as "merged"
| ||
This page was originally created for VetView 2.0.12 in December 2020. It has been updated to reflect changes in VetView 5.0 on October 9th, 2024. |
| Live Search | ||||
|---|---|---|---|---|
|
| Table of Contents | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
| Note |
|---|
Both Episode Problems and SOAPs have been moved from being discrete Patient Record elements on their own to being part of the Catalog elements system. This allows for more flexibility when creating the kind of SOAP forms that you want your clinical staff and students to fill out based on the kind of episode and patient that they are working with. Please see Catalog Setup in 5.0 for details in building these new documents with the elements. |
Episode Problems in a Document
To add a problem to an episode, you must first add a Document with a Problem element.
Adding a new problem from a document
Problems can be added in two formats: Either directly from a value list that your Hospital has pre-assigned to all Problems within the system, or as free text.
...
If your Hospital allows for free text in addition to the Problem list, you can enter anything that you want.
...
While you are working on the Problems for a patient, you can add and remove them as needed.
When you are done, be sure to click on the Save New Problems button to add the Problem to the official Episode Problem list.
...
Problems to the Master Problem List on the Visit Summary Tab
Problems that are added to the Visit Information tab on an episode will automatically be added to the Master Problem List on the Visit Summary Tab.
These problems can be manipulated on the patient record itself or on the MPL as part of differential diagnosis.
...
Add a Diagnosis as a Problem (5.0 and later)
If you have Diagnosis codes that are built as lower level problems for differential diagnosis, you can now access these from the Problem menu directly and treat them as problems.
Like Problems, they will be added to the Master Problem List on the Visit Summary Tab, where they can be manipulated. And on the episode, they can be SOAPed.
...
| Panel | ||||||||
|---|---|---|---|---|---|---|---|---|
| ||||||||
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.
SOAP Due Dates
The due date for a SOAP is determined by a Catalog Setup option on the catalog item. This allows you to have a unique due date for different SOAPs - one for students who are performing junior surgery labs, one for senior students doing clinical rotations, one for residents and interns, etc. By default, it will be 8AM on day 2 after the SOAP was added to the patient record. This may be less than 48 hours depending on when the SOAP was added.
...
This deadline appears at the top of the SOAP document so that students can clearly see when the assignment should be submitted for Review.
...
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:
...
When the document is open for editing, you can add the text elements to each portion of the SOAP before selecting the problem, as appropriate.
...
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.
| Panel | ||||||||
|---|---|---|---|---|---|---|---|---|
| ||||||||
As part of the improvements in 5.0, all document categories now have a basic default document template, including SOAPs. This is named the VetView Default in the Templates list. 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. In this example, the unit has a document named Problems and a document named SOAPs in addition to the VetView default SOAP template.  |
Edit Problems on the SOAP
Problems can be actively managed on the SOAP as you are working on the patient.
...
Merge one problem into another problem
Rename a Problem
Set a Problem as Inactive: This button will also prompt you to “Remove from Report?” if you no longer want it to be on the SOAP. Choose “No” if you want it to stay on the SOAP even though it will no longer be Active.
Set a Problem as Active (from Inactive): Inactive problems on a SOAP can be returned to Active status at any time.
Resolve the problem
Remove the problem (set to Deleted status):
For Remove you will also be prompted to remove it not only from the SOAP document, but from the Master Problem List as well. Choose either or choose Both to clear it completely if it was added in error.
...
Manage SOAPs: Submit for Review and Verification Workflow
...
Faculty supervisors who have the Manage SOAPs privilege have additional options available on the cases for their students. The expected workflow for a SOAP is as follows:
Student: Writes SOAP, submits for Review
Supervisor: Reviews SOAP, and requests that the student Revises if needed
Student: Makes revisions, submits for Review again
Supervisor: If no more revisions are needed, the supervisor can Verify the SOAP to indicate the work is completed
Other Manage SOAP options
In addition to the verification workflow, the Manage SOAP privilege allows a supervisor to perform certain actions on a SOAP to help maintain the integrity of the patient record.
Delete SOAP
If a SOAP was added by accident when the student only intended to add a new problem to an existing SOAP, the supervisor can delete the additional document.
Edit Created Date
Use this option when a SOAP was added too early in the episode. SOAPs are due 1-2 days after the date they were added to the patient record; if a SOAP was added too early on an episode by a student and they’ve already performed work on it, they can ask their supervisor to modify the date and time to allow them to complete the work before the deadline.
...
Reopen
If a SOAP was verified but additional work needs to be done on them afterward, the Supervisor can Reopen the SOAP to allow for the Review-Revise-Verify process to be completed a second time.
This option is only visible after Verification has been completed.
Document Options on SOAPs: Charges, Personnel, Attachments, Print
In VetView 5.0, since SOAPs are now considered to be standard Documents, you have all the same options available on SOAPs that are available on other documents as long as you have the appropriate privileges.
Charges
In the unlikely event your hospital wants to track a product against SOAPs, this can be done using the Charges button. These are considered Request charges or Document charges depending on whether your SOAP is considered a Request or Document within the patient record.
In this example, the SOAP is considered a request charge.
...
Personnel
A much more common use case for SOAPs would be adding Personnel. The student(s) who are completing the SOAP can be added as the users, and the supervising faculty member as well.
| Panel | ||||||||
|---|---|---|---|---|---|---|---|---|
| ||||||||
Note that as of VetView 5.0, the last updated user and date/time for the person who added and last Saved and the person who Verified are tracked independently.  |
Attachments
Externally scanned documents can be attached directly to the SOAP. This may be a helpful option for a student to attach a scanned worksheet such as a drawn Body Condition Score, or other scanned PDFs like a graph or imaging that doesn’t have an interface to VetView.
Once it is attached, you can modify the attributes of the attachment. You can also have it appended to the end of the report, or have it replace the report entirely in a printed version of the medical record - use these options if the SOAP was graded on paper and scanned.
...
The SOAP can be printed like any other document. Note that at most universities, SOAPs are protected by FERPA, but they can be printed to help with the Review process if the supervising faculty wants a written version, or as part of the patient’s permanent record.
Like any report, these can be customized to display your university or clinic’s logo.
...
Master Problem List on the Visit Summary Tab
The Master Problem List has been moved to a widget on the Visit Summary Tab.
We recommend having this widget set as one of the first, alongside the patient demographic widget, to provide an at-a-glance view of any known issues with a patient.
Problems are automatically numbered on the MPL. This number is permanent and will remain next to the problem even if you sort the problems to a different priority using the arrows.
Master Problem List Types and Sources
Episode Problems added via a document are automatically added to the Master Problem List. The Type column displays whether it was a Problem or a Diagnosis. The Source column in this table displays which portion of the episode the Problem was added from.
Problems can also be added directly to the Master Problem List outside of an episode by clicking on the Edit Problems button.
...
This button loads the new Edit Problems Window. Within this window, you can manage the problems on the Master Problem List, in the same way you can manage them from a document on the Episode.
...
If you add a new Problem directly from the MPL Widget, the Source for the problem will display as the Master Problem List.
...
Sort Problems on the Master Problem List
You can prioritize the problems on the MPL by selecting a problem and clicking the Sort button.
Note that the assigned numbers are permanent and cannot be altered, but you can have the most important issue at the top of the list, and sort inactive and resolved problems to the bottom.
...
Select the row you want to sort, and use the Move Up and Move Down arrows to sort the problems into the desired order. This process saves automatically
Show History / Active List
The Show History button on the MPL will change the view from the current list of problems to display a list of any problems that were set as inactive, had their names changed, or were merged.
After Show History is clicked, the button itself will change and the name will become Active List. Click on this button to return to the original MPL view.
...
| Warning |
|---|
Any problems that were deleted from the patient record will appear in the Show History section with a strike through, and their original history will also appear. In the example above, |
Manage Problems: Merge, Inactivate, Resolve
Within the Edit Problemswindow, you can manipulate the problems and set them as inactive if they are no longer present in the patient.
Merge problems
If problems were duplicated at some point, for example via both a Diagnosis and a SOAP, you can select one problem and click on the Merge button. A small window will open.
...
Select the second problem that the first problem will be merged into:
...
Once you click the Merge button, the two problems will be joined together in the background, and only the problem that was set as the “Merge To” will remain on the Master Problem List.
You can view any merged problems by clicking on the Show History button on the MPL to see the changes.
...
Set Problem as Inactive
If a problem is no longer presenting in a patient, but you are not certain it is resolved, you can set it as Inactive until you have further confirmation that the problem is present or not. Many times animals appear to be better temporarily, or their owners no longer observes the original issue, but the underlying ailment is still there. The Inactive status permits you to bring back a problem to SOAP at any time.
...
Resolve Problems
If a problem truly has been resolved - identified, treated, and not observed again for a period of time - you can mark it as Resolved on the Master Problem List by clicking on Edit Problems, selecting the problem from the list, and then clicking on the Resolve button.
...
The status of the Problem will change to Resolved. If a problem returns, it can be set as Active again at any time - Resolved is not a permanent status on the MPL.
...