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.

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 selection 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.

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.

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:

1. 

   Student: Writes SOAP, submits for Review

2. 

   Supervisor: Reviews SOAP, and requests that the student Revises if needed

3. 

   Student: Makes revisions, submits for Review again

4. 

   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.

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 on SOAPs.

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.

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.

Print

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 versus Episode Problems

Episode Problems added via a document are automatically added to the Master Problem List.

Problems can also be added directly to the Master Problem List outside of an episode by clicking on the Edit Problems button.

(replace screenshot once new build is live)

Manage Problems: Merge, Inactivate, Resolve