Patient Clinical Charting and SOAP Notes Software
Reviews and Ratings
Easy to use point of care patient clinical notes and charting software within your EMR /EHR will benefit the physician, the medical billing software specialist, and of course, the patient. Happy is the doctor who can take accurate notes with ease at the time he sees the patient, and not wait for his notes to be transcribed.
Patient clinical notes — which used to include paper SOAP notes, before the advent of EMRs — are the heart of the EMR because they contain the complaints, diagnoses, and the doctors’ treatment plans. Since they are tied into the billing, they also contain the diagnostic and procedure codes which will be used to bill the patient and his insurance company. And this was the case on paper bill as well.
The trick is to find SOAP charting software that is flexible and simple to use. It needs to be easy to find and consolidate notes when the examining doctor himself goes back through a patient’s history, and easy to pass on to another doctor. A major problem in EMR clinical notes is the lack of flexibility: some EMR’s make the doctors choose between drop-down menu choices that do not accurately meet their diagnoses.
Many doctors just beginning to use EMR for clinical notes find that they cannot handle their normal patient load because they are spending so much time learning the software. Obviously, there will be a learning curve, but in well designed EMR software, that learning curve should be short, and the path to using it well an intuitive one.
Poor patient charting software makes the doctor concentrate on the notes more than on the patient and his care. If you are exploring a new EMR, make sure to try writing some clinical notes yourself. Set up a test-case patient with a complex diagnosis, and see how difficult (or easy) it is to set up clinical notes for him.
Another problem in EMR clinical notes is not being able to go back and revise notes. Some systems will let you set up an addendum (like putting a yellow paste-up note on a paper) but not to revise the note itself. A system that would give more flexibility to you when creating and revising or updating clinical notes would certainly be better.
An EMR that makes it easy to write digital SOAP notes will also benefit the practice’s billing and medical practice management functions as well, and help ensure that CPT coding is done accurately, so that accurate diagnoses and billing information can be submitted to the correct insurance company.
Patient-centered documentation can improve the quality of patient care while reducing overhead and administration costs. Providing a more streamlined workflow can enhance productivity, ensure HIPAA compliance, and generally provide for better patient outcome. Capturing medical patient data at point-of-care eliminates duplication and ensures a more faithful medical record for the patient and the provider.
If you are moving toward an Electronic Health Record (or contemplating an upgrade to a new EMR system) which integrates patient management with practice management data, you will want to see your entire practice working off the same integrated database. If you are looking for an EMR that will integrate with an already existing but separate Practice Management Product, you will want to make sure that the EMR you lease or buy interfaces easily with your current Practice Management product.
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Sheldon Needle, CTS President has been publishing reviews of medical software since 1990.