How to build an SO template 841 With

How to build an S/O template (841) With 841 you can actually build all aspects (SOAP) of a template at once

§ Go to template management and click new

§ The tabs displayed show the various template building functions

Link Templates § You can link one or more existing templates to any template you are creating. When you use a template containing linked templates, the contents are automatically merged into the encounter.

Link Templates § To link a template to the new template: § 1. Click the Linked Templates tab. § 2. Select the template from the left pane and click Link. The template contents are added to the Template Preview pane. § 3 To view the details in the Template Preview pane, expand the item(s) you want to preview.

Link Templates § To preview the contents of a template, prior to linking it, select the template in the left pane and click the Preview button at the bottom of the left pane. The contents of the template display in the right pane. Click the Cancel button to close the preview. § To remove a linked template, expand Linked Templates in the right pane and select the linked template you want to remove. Click Unlink at the bottom of the left pane.

To add HPI terms to a template: § § 1 Click the HPI tab. The default Medcin tree displays in the left pane. § 2 Select items to add to the template by clicking the large plus sign (+) next to the items. The items selected will display under the History of Present Illness category in the right pane. § 3 If necessary, you can expand items to view . and select additional terms

To add HPI terms to a template § If you want to view a list of other terms that may be associated with an item, highlight the item itself (Do not click the large plus sign), and click the Prompt button. § If any items are available and appropriate, you can select them for inclusion into the template. § Click Go Back to return to the previous screen when finished.

Adding PMH Terms § PMH terms deal with common questions concerning previous hospitalizations and family and social history. Findings should be selected that reflect what you normally ask a patient. § 1 Click the PMH tab. The default Medcin tree displays in the left pane. § 2 Select items to add to the template by clicking the large plus sign (+) next to the item. The item selected will display under the History category in the right pane. § 3 If necessary, you can expand items by clicking the expand icon (small plus) to view and select additional terms. § Items can be removed from the template by highlighting the term in the template preview pane and pressing the Delete key on your keyboard.

Adding PMH Terms § If you want to view a list of other terms that may be associated with an item, highlight the item itself (Do not click the large plus sign), and click the Prompt button. § § If any items are available and appropriate, you can select them for inclusion into the template. § Click Go Back to return to the previous screen.

PMH § To indicate that the patient has a history of a finding: § 1 Select the finding in the left pane. § 3 Click the History button to add the "History of" prefix to the finding, or § § 4 Select a more precise option from the History dropdown list. § Your selections will display under the History category in the right pane.

§ To indicate that the patient has a family history of a finding: § § 1 Select the finding in the left pane. 2 Click Family History button to add the "Family History of" prefix to the finding, or 3 Select a more precise option from the Family History drop-down list. Your selections will display under the History category in the right pane. § § § When you made your selection from the drop-down list, the name of the item also changed in the left pane to agree with the finding added to the right pane.

§ To indicate that the patient has a family history of a finding: § § 1 Select the finding in the left pane. 2 Click Family History button to add the "Family History of" prefix to the finding, or 3 Select a more precise option from the Family History drop-down list. Your selections will display under the History category in the right pane. § § § When you made your selection from the drop-down list, the name of the item also changed in the left pane to agree with the finding added to the right pane.

§ To add ROS terms to a template: § 1 Click the ROS tab. The default Medcin tree displays in the left pane. (The items that you had previously selected when adding HPI terms are shown as selected. You can flip the items between HPI and ROS by clicking the ROS/HPI button). § 2. Select items to add to the template by clicking the large plus sign (+) next to the items. The item selected will display under the Review of Systems category in the right pan

PMH § Items can be removed from the template by highlighting the term in the template preview pane and pressing the Delete key on your keyboard. If necessary, you can expand items to view and select additional terms. § If you want to view a list of other terms that may be associated with an item, highlight the item itself (Do not click the large plus sign), and click the Prompt button. § If any items are available and appropriate, you can select them for inclusion into the template. § Click Go Back to return to the previous screen.

Physical Exam (PE) § To add PE terms to a template: § § 1 Click the PE tab. The default Medcin tree displays in the left pane. § 2 Select items to add to the template by clicking the large plus sign (+) next to the items. The item selected will display under the Review of Systems category in the right pane. § Items can be removed from the template by highlighting the term in the template preview pane and pressing the Delete key on your keyboard. If necessary, you can expand items to view and select additional terms. §

PE § If you want to view a list of other terms that may be associated with an item, highlight the item itself (Do not click the large plus sign), and click the Prompt button. § If any items are available and appropriate, you can select them for inclusion into the template. § Click Go Back to return to the previous screen.

Tests § To add Tests data to a template: § 1 Click the Tests tab. § The default Medcin tree will display in the left pane. § 2 Select items to add to the template by clicking the large plus sign (+) next to the items. § The item selected will display under the Review of Systems category in the right pane. § Items can be removed from the template by highlighting the term in the template preview pane and pressing the Delete key on your keyboard.

Tests § If necessary, you can expand items to view and select additional terms. § If you want to view a list of other terms that may be associated with an item, highlight the item itself (Do not click the large plus sign), and click the Prompt button. § If any items are available and appropriate, you can select them for inclusion into the template. § Click Go Back to return to the previous screen.

Browse Function § You can browse through several Medcin trees to select and change data related to the S/O part of the template. § To browse terms through the Medcin trees: § 1 Click the Browse tab. § A listing of the Symptoms, History, Physical Examination, and Tests Medcin trees will display in the left pane. § 2 Expand each tree as desired to view available options that can be added to the appropriate category in the right pane.

§ In 841 you can also add terms to the AP portion of the template to make a complete encounter template

Save When you are finished § § When you have completed the contents of the template, click Save on the Action bar and the Save template window opens. Enter the name of the template in the Template Name field. § Select the type of template that you want the template saved as from the Save In drop-down list. § Select a specialty from the Specialty drop-down list, as appropriate. Select the Shared checkbox to designate the template as shared. § § Click Save and the template is saved in the location you specified and is available for use in a patient encounter.