Examples > Wellness ERP System > 102.5 - SOAP Notes (Medical Records)
Google Drive offers a Business Associate Agreement (BAA) for Google Suite Customers. This means at a technology level you are HIPAA compliant. You will still need to have proper use produres like passwords on devices and such to be fully compliant, but the baseline technology is covered, and that is a HUGE deal...
We look at the SOAP notes from two angles...
We look at the SOAP notes from two angles...
- Manual notes can be scanned and stored for easy access
- Notes can be created and stored in Google Sheets
The handwritten medical note is the most efficient note on the planet. Bar none, and I'll bet a lot of wellness practitioners are breathing a sigh of relief with that statement.
You can setup paper forms with lots of stuff and circle and check and draw -- all of which results in a picture that is worth 1000 words. This desire to make SOAP notes a "database application" is being driven by all kinds of interests that don't necessarily have either a patient or a practitioners best interest in mind.
From a technologists perspective, it is in fact far more problematic than I would have imagined until paying more attention to it from around 2008ish. While I thought it was just bad programming that was causing the issues, it wasn't until I actually started working with wellness practitioners as a business process consultant that I realized just how problematic electronic note taking was from about 10 different angles...
Holy crap... putting doc into a paradigm where they are supposed to use elecronic note taking tools in real time is simply problematic -- and we haven't even touched on the concept of the way it interupts all types of intutive processes that most western docs won't tell you they engage in openly (for those that can/do).
You can setup paper forms with lots of stuff and circle and check and draw -- all of which results in a picture that is worth 1000 words. This desire to make SOAP notes a "database application" is being driven by all kinds of interests that don't necessarily have either a patient or a practitioners best interest in mind.
From a technologists perspective, it is in fact far more problematic than I would have imagined until paying more attention to it from around 2008ish. While I thought it was just bad programming that was causing the issues, it wasn't until I actually started working with wellness practitioners as a business process consultant that I realized just how problematic electronic note taking was from about 10 different angles...
- If the person isn't a technologist it can be problematic
- If the person doesn't have a technology support person in the office at all times, it's very problematic
- Windows and Macs are problematic
- Internet connections are problematic
- Cloud computing is problematic
- Offices where electricity can get cut off is problematic...
Holy crap... putting doc into a paradigm where they are supposed to use elecronic note taking tools in real time is simply problematic -- and we haven't even touched on the concept of the way it interupts all types of intutive processes that most western docs won't tell you they engage in openly (for those that can/do).
Option 1 - Write It, Store It, Scan It and Recall It
We have come up with a system that is nothing short of amazing for small (and mid size wellness practices as it relates to storing and filing of handwritten notes.
- Create Paper Forms
- Buy a Sorting Bar and designate an appropriate space for it
- Select a scanner appropriate for your needs
- Configure your recall devices for Google Drive Access
If you create multiple per page that log will be filed by date and you will use your digital calendar to recall those dates of service. The single page items can either be stored by date or by patient. While you may think recalling information would be cumbersome, it is in fact far quicker to store and recall digitally than anything you were doing by hand. The only exception to that would be looking at a long sequence of case history for a single patient if you only use multiple entry per page ledgers.
With some thought, you can customize this system any way that works best for you.
With some thought, you can customize this system any way that works best for you.
Step 2 Involves a $12 sorting bar-- For patient specific items you want to store in their own digital folder, you can stage docs for 1 day, 1 week, 1 month 1 quarter or longer, depending on your patient flow and your desired scanning schedule. These docs together act as travel cards but you likely wouldn't think of it this way until we showed this to you -- and after we do and if you give it a try, you will likely just chuckle.
Given the shape of this item and the material it will be storing, and given a probable need to access it daily, you will need to think about a proper storage place for this item.
Given the shape of this item and the material it will be storing, and given a probable need to access it daily, you will need to think about a proper storage place for this item.
Step 3 involves a Fujitsu Scan Snap or comparable -- Step three involves the scanning of docs in packets by patient. What may sound like a long and tedious process is in fact incredibly quick -- much quicker than you could ever manually file documents. Truth be told -- if you are just getting going or in a low volume practice, a $5 scanner app for your phone would in fact work just fine...
Step 4 is the digital recall -- that is a piece of cake from any Google Drive Connected device... and you can view or print if needed...
You will recall by customer folder or by visit date(s).
You will recall by customer folder or by visit date(s).
Option 2 - Digital Database...
We have created a digital database system. There are typically two parts to it. There is a ledger style entry system in which visit basics are stored for each patient and then there is a longer notes section that is used on an as needed basis to supplement the ledger information.
The remaining portion of this page is the documentation for Option 2 -- the digital version of SOAP Notes
1 - SOAP Notes - Ledger
The ledger can look like anything you'd like.
Your text could in fact be higher than a single line, but it would all need to be contained in one row, so the lines would need to wrap.
There is an "Archive" button that is used to move these from this active screen to a data table (small javascript routine). That could be used after every patient or at the end of the day. The point here is that you are not working in your primary data table (which you could do as well if you'd like). And that ARCHIVING function can be manually done instead with Ctrl-X and Ctrl-V... just cut ant paste the records for long term storage.
Your text could in fact be higher than a single line, but it would all need to be contained in one row, so the lines would need to wrap.
There is an "Archive" button that is used to move these from this active screen to a data table (small javascript routine). That could be used after every patient or at the end of the day. The point here is that you are not working in your primary data table (which you could do as well if you'd like). And that ARCHIVING function can be manually done instead with Ctrl-X and Ctrl-V... just cut ant paste the records for long term storage.
2 - SOAP Notes - Extended Notes
For extended notes that may not always be needed, you can use a different ledger. It too has an Archive function (or just cut and paste).
3 - SOAP Notes - Archive
Archived SOAP notes retire in this data table. It is a mirror of the table the notes were entered in.
4 - SOAP Notes Extended Archive
SOAP notes extended Archive is a mirror of the entry page.
5 - Search SOAP Notes
While you can certainly use Google Sheets filters on the data table, we've created a reporting tool that is nicer for reading and for printing...
Printed, this report looks like this...
This is the first of these types of reports we've seen and they have a slick system in the hidden header that you will see in all similar style reporting... The bottom box with the grey and purple is incredibly powerful. It is not in full use here. It is only in partial use. It is in full use in the ZAP Accounting Software files.
6 - Search SOAP Notes Extended
The same functionality exists for the extended notes...
With this printed report looking like...
And there is a nearly identical hidden Header section that was used to create this report. We did not include a picture.
Summary
The digital SOAP note system seems cool. It is customizable easily for different practices. It has great storage and recall capabilities, but what happens when one of 10 things happens to the digital connection?!!?
Those that opt for the digital route need manual backup processes and they need to realize they will be duplicating efforts when they go manual, unless they just decide to scan those docs as opposed to re-entering data when the systems are back up and running again.
Those that opt for the digital route need manual backup processes and they need to realize they will be duplicating efforts when they go manual, unless they just decide to scan those docs as opposed to re-entering data when the systems are back up and running again.