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Set up and use Clinical Charting Templates (SOAP, Clickable and Dot-Phrase)

Richard Abujasen
Updated

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In OptiMantra, we have three main types of templates to facilitate quicker charting:

 

 

Please see the below articles that cover other sections inside the Settings > Clinical Templates:

 

 

Use just one of these charting templates, or you multiple types of templates together. 

  • Each of the template areas have a Template Library Button that you can click to reference templates that have been created by OptiMantra or shared by other providers. 

  • You can import these templates to be added to your own library and adjust them as you'd like.

 

The below video provides an overview on how to set up Clinical Templates in OptiMantra.

In OptiMantra, please open Settings> Clinical Templates

 

SOAP Templates (Text-based)

This template allows you to copy whole paragraph(s), with or without fill in the blanks, as macros to speed up your charting.

  • You can write the full chart note with all four SOAP sections or using the G(eneral) note or you can use just individual parts. For example: 

    • We recommend creating the templates to be for 1 of the SOAP sections:

      • S (Subjective)

      • O (Objective)

      • A (Assessment)

      • P (Plan)

      • General (used only in basic notes)s

    • Or, if I have a Detox template I want to use it for my Plan section, I can copy paste the text in only the Plan tab and specify which practitioners have access to it
  • Make sure you assign the template to the providers who need to see it in the top right of the page! Only providers checked off will have access to it in their chart note.

 

 

In the charting, you can then import it by clicking on the "Import SOAP Template" link.

  • This will automatically populate every section of the chart note you'd filled out in the template
  • If you already wrote text into your chart note, the template will be added to your chart (it will not overwrite your existing text)
  • Note - If you don't see a chart note, check your access under Settings, or make sure you're using the right type of chart note (e.g., if you're using a Basic Note instead of a SOAP style chart note, you won't be able to pull a Subjective section into the General section of your Basic Note)

 

 

 

Categorized Clickable Templates 

This type of template allows you to create sentences on the fly using predefined choices

  • Each Category will be your clickable subject, and the items are your underlying details
    • Add different options you typically click and you can also add an N/A option 
    • You'll still be able to type any details in your chart note, so the categories don't need to be all-inclusive
  • For example, if you conduct a Range Of Motion test or exam, you can set up the choices in the program

 

 

 

 

If you're using the same clickable template all the time, you can then set-up a default template for a practitioner that will load the  template into your chart note so it shows up automatically when you open a new chart

  • You won't need to pull it in every time - this is very useful for templates like Review of Systems (ROS) or a Mental Status Exam (MSE) which you may be doing in every visit

 

 

 

 

 

@ (Dot)-Phrase Templates

 

This type of template allows you to quickly pull up pre-existing content 

  • First create a template or pull from our library of content

 

And, in the charting section, you can call up this text by input inputing the @sign and then the first 3+ letters of the template name; select the right template and the text will auto-populate in your note

  • This is commonly used for snippets of text you drop in all the time like @normal_MSE, medication descriptions, or lifestyle recommendations 
  • You can also use dot/@-phrases in other parts of the program like patient portal messaging and Tasks, email templates, and the Send Records feature so it's very versatile!
     

 

 

Other Charting Shortcuts

In addition to using dot/@-phrases, you can also use #diag and #meds to pull up details from the patients chart and quickly insert it into the chart note:

 

 


 

 

 

Charting Tags

Finally, at the bottom of the charting section, you add Tags to specify what type of note it was to quickly later search e.g., for all your Pelvic Therapy visits or all your Botox charts.

 

 

 

 

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