the interactive SOAP sheet
Physicians follow a specific process when seeing a patient. Â It is a progression of steps taken, documentations made and assessments noted. Â The Interactive SOAP Sheet, (ISS), leads the physician through this process step by step. Â Each screen utilized throughout the exam process provides the necessary information needed at each stage of the exam. Â With this approach to the EMR, the physician has on each screen the information he needs at the time it is needed. Â Pal/Med provides opportunities for documentation at each stage of the patient encounter.Â Standard dictations are available for positive and negative findings and are entered easily with selection of a check box. Â Once the information is saved, the patient chart is automatically updated. Â This update happens in "real-time", while the physician is with the patient. Â This avoids errors and omissions that can happen when dictation or charting is put off until after the patient encounter is completed. Â When all the tabs of the ISS have been visited and the exam is complete, no further charting is needed.Â
KEY FEATURES:Â Â
- tabs for each step of patient encounter
- Â standard dictations for positive and negative findings
- tabs for systems of the body
- screens focused on patient encounter
- most recent progress notes
To be clinically useful to the physician, information must be at hand at the time of decision making--while the physician is in the exam room with the patient. Â This is the primary function of the interactive SOAP sheet.
A Pal/Med exclusive:
Interactive Soap Sheet or â€œISSâ€?
While similar in look and feel to our patient chart, the ISS gives the physician an organized approach to each patient encounter. Tabbing through the ISS from left to right, an exam is handled in the following order:
Â Â Â Â Â Â Here the physician can quickly review the patientâ€™s current problems, medications, allergies, operations, illnesses and current clinical decision alerts.
Â Â Â Â Â Â The physician can review the patientâ€™s last progress note, recent labs (since last visit) and recent nursing notes (since last visit)
Â Â Â Â Â Â The physician can review the Patientsâ€™ chief complaint and subjective findings.
â€œROSâ€? Review of Systems
Â Â Â Â Â Â Utilizing â€œreal-time chartingâ€? a physician or staff member can chart a complete review of the bodyâ€™s systems as the exam takes place.
Â Â Â Â Â Â The physician can quickly review all procedures, surgeries, illnesses, injuries and social history from the patientâ€™s past.
Â Â Â Â Â Â This is where the patientâ€™s vital signs for todayâ€™s visit are recorded or reviewed (if previously entered by the nurse) Â Note: When Ht. and Wt. are entered the BMI is automatically calculated, and multiple graphs of VSâ€™s, including a growth chart are available.
Â Â Â Â Â Â Utilizing â€œreal-time chartingâ€? and a tabbed, systems based approach; the physician can quickly navigate through the patientâ€™s body systems, notating positive or negative findings with an easy â€œcheck boxâ€? selection tool.
Â Â Â Â Â Â The physician can view a list of current problems and make additions to the problem list based on the current visitâ€™s findings.
Â Â Â Â Â Â Here the physician can enter orders for the patient, such as labs, tests and procedures.
Â Â Â Â Â Â This tab is utilized to prescribe or refill medications. Â Prescriptions can be sent to the pharmacy electronically or a paper prescription generated.
Â Â Â Â Â Â The physician can select the follow up appointment timing and other interventions or consultation that Â may be needed.
Â Â Â Â Â Â This is where the physician selects the level of care and other services provided by the practice and billed for by the practice. Â This data may be directly posted to the patient ledger with proper billing software interface.
Â Â Â Â Â Â This document provides an overview of the patient encounter. Â It also contains a list of current problems and medications. Â The summary sheet may be printed for the billing clerk, patient or consultant. Â It may also be exported in CCR format. Â In addition, patient education sheets pertinent to the patientâ€™s problems may be selected form this screen and printed.
EMR Software Companies
Copyright 2011: Pal/Med Development. Electronic Medical Record Software. All rights reserved.
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Cape Girardeau, MO Â 63703-6364
Pal/Medâ€™s is different in its approach to electronic medical record software. MostÂ EMR software companiesÂ have written electronic medical record software that simply allows the physician to save patient information in a digital format. In contrast, Pal/Med provides a unique exam tool for the physician to assist in the exam process. Additionally, Pal/Medâ€™sÂ EMR source codeÂ is available for organizations that desire full control of their electronic medical records. This is what separates Pal/Med Development from otherÂ EMR software companies. Â
Pal/MedÂ is a leader among