How to build an SO template 841

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How to build an S/O template (841)

• With 841 you can actually build all aspects
  (SOAP) of a template at once

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• Go to template management and click new
  
  

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• The tabs displayed show the various template
  building functions

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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
  drop-down list.
• Your selections will display under the History
  category in the right pane.

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• 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.

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• 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.

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• 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

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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.

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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.

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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.

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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.

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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.

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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.

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

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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.