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Online Medical SOAP Notes

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Electronic Medical Record (EMR) Systems
While modern electronic medical record (EMR) systems have, in many ways, been a tremendous success, they have ultimately failed to communicate with each other in any meaningful way, forcing the medical provider to adapt their documentation habits in an ever-changing environment.  One recalls the narrator from the 1980 film The Gods Must Be Crazy who pointed out that “…civilized man, who refused to adapt to his surroundings now finds he has to adapt and re-adapt every hour of the day to his self-created environment.” 
  • Are our EMRs adapting to our work flow, or are we adapting to them?
  • How does this impact our efficiency?
  • How does this impact our patients?
At SOAPassist, we believe that medical documentation should be adapted to the practice of the individual provider and should be consistent across all practice settings, regardless of EMR.  It is better for the provider.  It is better for the patient.

The plethora of EMRs has resulted in medical providers having to adapt to their clinical environment rather than the environment adapting to their practice.  So why aren’t all EMRs similar?  At the very least, why don’t they talk to each other?  Afterall, they are all online.  We all know the answer.  There are many companies producing EMRs, and despite some attempt to achieve interoperability, most providers move from practice setting to practice setting using different EMRs that do not communicate.  Worse still, it is not uncommon for medical providers to use several EMRs in a single practice setting. So how do you create a method of documentation that is adapted to the practice of the individual provider and compatible with the many modern EMRs? That is where SOAPassist comes in.  SOAPassist is an online medical template service that is specifically designed to adapt to the individual provider’s practice.   It utilizes customizable templates that can be summoned at a moment’s notice.  The templates are instantly and seamlessly integrated to create a custom SOAP note.  Medical providers can access their templates and create custom SOAP notes wherever they have internet access.  All that remains is to copy the online medical SOAP note into the EMR.  From a medical documentation standpoint, the problem of interoperability has been solved.

Simply put, a unified documentation experience is better for the provider.   Time and  time again, EMRs and computerized physician order entry (COPE) have been cited as contributors to provider burnout.  Nobody desires to go through so much education and training for the purpose of helping people, just to struggle in front of the computer day in and day out.  No, providers want to be with patients.  They want more face-to-face time in the clinic.  They want more time in the operating room.  They want to spend more time helping patients and less time writing about it.  SOAPassist helps accomplish this by reducing the time spent with documentation.

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Efficient methods of documentation means less time in front of the computer, which means more time with patients.  Patients develop relationships with their providers.  Trust is established.  Questions are answered.  Counseling is provided.  But what if documentation could help you make a diagnosis sooner?  What if it could prevent additional hospital days?  Working from an understanding that all providers are human and sometimes forget to ask questions that impact workup and treatment, SOAPassist has developed its documentation process such that templates provide prompts to ask these important questions.  This allows you to consider more diagnoses at the initial encounter, get to the right diagnosis sooner and begin treatment more rapidly.  Each provider knows which questions they always seem to forget to ask, diagnoses they forget to consider and orders they forget to place.  Templates customized to the practice of the individual provider can minimize these occurrences.  Efficient documentation not only means more time with the patient, but more effective time with the patient.

Ultimately, efficient documentation can only be accomplished when it is adapted to the practice of the individual provider and is consistent across all practice settings, regardless of which EMR is used.  Through the use of online medical SOAP notes, SOAPassist empowers providers to maximize their documentation efficiency resulting in greater job satisfaction and improved patient care.

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