Log In Logging in to SpineTech SOAP: On the left side of the screen you will find instructions for the initial login process after you have registered with SpineTech SOAP. 1. Enter your assigned clinic ID. This is the ID contained in your Registration e-mail. 2. Enter your user name. Each additional user will have its own username and password. The Username is also contained in your registration email. 3. Enter password. Your password is the password that you selected during sign-up. It is not contained in the e-mail. 4. Touch "Login". If you have forgotten your password, touch the forgot password button and follow the steps to recover your password. SpineTech SOAP Help Manual Page 1
Adding a New Patient to Database From the main page of spinetech you may add a new patient, select and existing patient, access the settings menu, search patient appointments, sync your device, and view and add appointments. To add a new patient: 1.Click on the "Add Patient" button with the "+" in the left corner of the main page. After selecting to add the new patient you will be taken to the Patient Information screen. SpineTech SOAP Help Manual Page 2
Adding New Patient Information To enter a patient into the system, first you must input all of his/her information into the program. 1. Begin by typing the patients name, birthday, social security number, e-mail address, the person whom referred the patient and maximum number of patient visits. 2. Select "Male" or "Female". Make sure that this option is correctly selected. The gender of the patient in the note follows the gender that is selected on this page. 3. Touch the "Statement" button to add a diagnosis. (See "Selecting a Statement") 4. Add an abbreviation for the patient complaint into " Enter complaint 1" box. For example: if the patient has cervical and thoracic complaint, you would enter "C/T". 5. In the " Enter description" box you will describe the patients complaint. (NOTE: DO NOT USE CAPITAL LETTERS AT THE BEGINING AND NO PUNCTUATION AT THE END. ) This is the discription that is inserted into the note anywhere [COMPLAINT X] is entered (see slide Editing a Section Heading and text (3 of 3)-Edit mode Cont...". For example: "dull aching in her cervical region with tightness in her thoracic region" 6. After all fields are complete, hit the save icon. If you have a question about the function of any of the buttons, you can hit the "?" button at the top of the screen for a description of the function. SpineTech SOAP Help Manual Page 3
Selecting a Statement A patients diagnosis is entered by hitting the "statement" button on the Add New Patient page. Packages of common diagnosis have been added to the program. They are numbered 1 to 11 for ICD-9 codes and 1-10 to 11-10 for ICD-10 codes. 1. You choose a diagnosis package by highlighting the circle next to the package. (For example: a Medicare lumbar/hip would be package number "9"). 2. You can also choose to search for a diagnosis statement by typing a key word into the search bar. 3. After the correct diagnosis' is/are chosen you hit the check mark button to save your selection. If you would like to add a new statement, select the "+" at the top of your screen. You will then receive a box on your screen to enter the package number and the Description. After both are entered, you hit "Save" to add it to your Statement list. To edit an existing statement, click the pencil icon. A text box will come up with the current information in it. From here you can modify information and make necessary changes. Click save when finished. SpineTech SOAP Help Manual Page 4
Choosing a Patient To select a patient that has been added to the system: 1. Click the "patient" icon to view the "Existing patient schedule". SpineTech SOAP Help Manual Page 5
Existing Patient Schedule To Create a New Note: 1. Type first name of the patient in the search bar. 2. Select correct patient from the "Patient Name" column. This will open a new note. This page also displays the patient ID, SS #, DOB, Date of last visit, Status, etc. 1. You can edit patient info by selecting the edit icon. 2. Open notes by selecting the notes icon. 3. View prior notes by selecting the clipboard icon. 4. View appointments by selecting the calendar icon. 5. View attached documents by selecting the documents icon. If you have a question about the function of any of the buttons, you can hit the "?" button at the top of the screen for a description of the function. SpineTech SOAP Help Manual Page 6
Creating a Note To create a new note: Today's date will automatically appear in the "Service Date" box. If doing a note for another date, be sure change the date in the drop down scroll menu that appears when you touch the date box. Using the buttons across the top of the note, you may Choose an introductory statement, a pain scale, time of service, and complaint for an introduction to your note. It is up to u wether or not you want this paragraph. Following the format of soap notes, click on "SUBJECTIVE", this will take you to the "SUBJECTIVE" main page. Choose the "edit Patient" icon to return to the edit patient information screen to change information or to add new statements. The Pencil icon is used to change the description inserted by any of the buttons on the page displayed. Click the pencil, then the button you wish to change. For example, You can click the pencil, then "Subjective" and change the wording of the heading inserted when this button is chosen. If you have a question about the function of any of the buttons, you can hit the "?" button at the top of the screen for a description of the function. SpineTech SOAP Help Manual Page 7
Menus in Each Section The (#1) title of each section is shown at the top of the screen. Select by touching the title to insert the word "SUBJECTIVE" into the note. The Horizontal menu (#2) is the main tool bar in each section. The vertical menu (#3) is the list of subsections for each item selected in the main menu. The Vertical menu (#3) is a list of subsections for the highlighted section of the horizontal menu. For example: This is showing "SUBJECTIVE" "Templates" "Maintence visits". To add a comment under "maintence Visits" click the "+" (#4) button, type the statement, hit "save" and it will be displayed in the list under maintenance visits. After selecting appropriate item from list, hit the check mark to add it to the note. For each selection in the main menu, the horizontal sub sections will change. Each subsection chosen will display its own list of statements for you to choose from. SpineTech SOAP Help Manual Page 8
Subjective Main Screen The "SUBJECTIVE" main screen is seen below. Always start each section by selecting the Heading button to insert SUBJECTIVE, OBJECTIVE, ASSESSMENT or PLAN into the note. The easiest way to do a simple day to day note for an established patient is to click on "Template" (#1) first. Then choose between (#2) SOA Better, SOA Same or SOA Worse, depending on the patients current condition. Under SOA templates, you will choose a general statement and it will automatically insert the SUBJECTIVE, OBJECTIVE, and ASSESSMENT sections into the note. If you choose to use these buttons, more information can be added by typing it into the displayed note on the main page. After Better, Worse or same is chosen, hit the "<" (#4) at the top of the screen to continue on with "PLAN". A second way to do the note is to choose between (#3) "Patient better", Patient Same" and "Patient worse" across the top of the screen. If done in this way, a statement will have to be added in the same way for each section. SpineTech SOAP Help Manual Page 9
SUBJECTIVE-Other A first day note, new complaint note, workers comp injury, or personal injury case note has to have additional information in it. All of these subjective details are listed under the SUBJECTIVE>Other button. As you can see the subsections on the left are Complaints, Affecting area, General history, and pain affecting daily life. Doing notes is simple following the format. Choose "Complaints" then Go in order across the options listed. For example for a new patient note: Begin by selecting SUBJECTIVE title bar to insert the heading. Next choose "Complaints" (#1). Choose "Chief Complaint" (#2). It will then bring up a page with pictures of anatomical regions. Simply touch the affected regions and hit the "<" (GREEN ARROW NEXT SLIDE) to return to this screen. Select "ONSET" (#3) or "Problem began DATE" (#4). Choose how many days,weeks months the problem has been an issue, or under "Problem began DATE" (#4) choose the date the problem began. Use the "<" to return to this screen. Select the appropriate button (#5) to indicate if the problem getting better, worse or staying the same. When you touch this button you will see it light up briefly where you touched. This shows that you have selected it. Selecting this button adds the statement about progression of the complaint to the note. Now you are ready to move to "Affecting area" (#6). Move through the selections in the Subsection menu in order and select only the buttons you need. When anatomy man shows choose body regions. When Date box shows choose appropriate time period. When Sliding pain scale appears, slide the circle to choose pain rating. After You have done each subsection on the left, your SUBJECTIVE section of your note is finished. Keep in mind you do not have to use every button only the ones appropriate for your patient. IMPORTANT: ALL OF THESE BUTTONS CAN AND SHOULD BE EDITED TO MEET YOUR PRACTICE REQUIREMENTS AND YOUR INDIVIDUAL PRACTICE STYLE. SpineTech SOAP Help Manual Page 10
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Choosing Anatomical Regions There are many buttons throughout the program that bring up a screen that looks like the one below. This screen is to choose anatomical body regions for complaint or areas of treatment. To use this screen: Touch within the screen anywhere(#1) to open the anatomy screen full size. Select the appropriate body regions (#2) for treatment or complaint that corresponds to the subsection you are currently under. For Example: for Low Thoracic and Lumbar regional pain,and Frontal region headaches you would select the pink circles indicated with the red arrows. After choosing appropriate body regions, Select the "<" (#3) button to return to previous screen. The Buttons in a row across the middle of the screen are used to further define detail if the area of complaint. The letters stand for the following: R-RIGHT, L-LEFT (#4). M-MEDIAL, L-LATERAL (#5). S-SUPERIOR, I-INFERIOR (#6). P-PROXIMAL, D-DISTAL (#7). SpineTech SOAP Help Manual Page 12
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Editing a Section Heading and text (1 of 3) All of the buttons and discriptions inserted into the note by choosing them can and should be edited to meet your practice requirements and your individual practice style. To edit a button and/or descriptive text: Highlight the button you wish to change(#1). Select the pencil icon (#2)in the top left of the screen. This will bring up a edit title box. If you do not wish to edit the title of the button hit cancel and you will remain in edit mode. From here you may change the descriptions of the item selected. Click save when finished editing. and use the "X" button at the top left of the screen to exit edit mode. SpineTech SOAP Help Manual Page 14
Editing a Section Heading and text (2 of 3)-Edit mode While in edit mode you will see a pencil and paper icon (#1) and an up and down arrows icon (#2) to the left of the description sentences. The up and down arrow icon (#2) is used to reorder the list. The pencil and paper icon (#1), when selected, displays a pop up screen that allows you to edit or change the descriptive statement that will be inserted into the SOAP note. (See Next slide for pop up Screen) After desired changes are made, select the "X" button (#3) at the top left of the page to exit edit mode. SpineTech SOAP Help Manual Page 15
Editing a Section Heading and text (3 of 3)-Edit mode Cont... After choosing the pencil and paper icon (#1 on previous slide GREEN ARROW), you will see the following pop up window. This window is used to change the templates descriptive text. (#1) Complaint Code- you may use your own complaint codes or just enter a short description in this line. (#2) You may change the text that is inserted into the note in this text box. ReplaceMent Text Buttons- The buttons across the middle of the pop up window are used to insert text off of the Patient information page into the note. (#3) Use these two buttons to insert the patients first or last name anywhere into the note into the note. Anywhere "[NAME]' is displayed in the test, the persons name will be inserted into the note. (#4) This button inserts the current date into the text wherever it is placed in the template. It will appear as "[DATE]" on the template. (#5) These buttons are used to insert the proper descriptive pronouns into the note. (#6) The [COMPLAINT X] button is used to insert the patients complaint into the note. This is the complaint that you added in the edit patient page when setting up the new patient. (#7) The [TIME} button inserts the time into the note. When you are done editing, Select "Save" (#8) to save your template. SpineTech SOAP Help Manual Page 16
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Edit Other Master Template Some of the templates you may edit look like the one below. This pop-up window is to edit a master template. The pop-up may contain an "Add" function (#1). The "Add" Options are: Screen Select (BLUE ARROW)- This allows the button to open one of the screens listed under "type" (#2). Open Note(ORANGE ARROW)- Opens note when the button is chosen. Key Pad (PINK ARROW)- Opens the key pad with measurements, and time periods when the button is chosen. Slider (PURPLE ARROW)- Opens the sliding scale when the button is chosen. None (RED ARROW)- Does not open another screen when button is chosen. The "Type" (#2) section is used to select the screen that the button will open. For Example: When using a complaint button, you will want the it to open the body region screen, Muscle Strength to open the Muscle Strength screen, area massaged to open the muscle map screen, etc... These Screens are shown and explained in the next 10 slides. SpineTech SOAP Help Manual Page 18
Body Regions This screen has pink circles for each different region of the body. Select as many body regions as appropriate for the patients complaint. For example: If your patient is experiencing pain in the right wrist, right anterior shoulder and posterior cervical pain, you would choose the circles shown (#1). The Buttons in a row across the middle of the screen are used to further define detail if the area of complaint. The letters stand for the following: R-RIGHT, L-LEFT (#2). M-MEDIAL, L-LATERAL (#3). S-SUPERIOR, I-INFERIOR (#4). P-PROXIMAL, D-DISTAL (#5). SpineTech SOAP Help Manual Page 19
Spinal The spinal page is one way to list types of adjustments, spinal subluxations, misalignment's, motion, etc. On the left is a list of different adjustment methods, patient positions, and spinal problems(#1). There are also "Empty" buttons (#2) that you may program (using the edit button) for methods that may not be listed. The yellow circles to the right of the screen (#3) are the vertebral body buttons. O- Occipital, C-Cervical, T-Thoracic, L-Lumbar, S-Scaral, C-Coccyx, The numbers listed under each represent the number vertebrae. The purple buttons to the right of the screen (#4) are L-Left, B-Bilateral, R-Right, Ant- Anterior, Post- Posterior. For example: You could choose "Subluxation->B->Post->C->5,6,7" This would insert into the note that the patient has subluxation bilaterally in the posterior levels C5-C7. SpineTech SOAP Help Manual Page 20
Extremity The Extremity page is used in the same way as the spinal page in the slide above. Begin by choosing the purple buttons to the left of the scree. that are appropriate for the patient problem (#1). Choose L-Left, B-Bilateral, or R right (#2). Chose the apropriate joint for the treatment, complaint, or subluxation (#3). Select either (#4) check mark to finish, the "X" to Cancel or the "Edit" Button to edit.. SpineTech SOAP Help Manual Page 21
Ribs The Ribs page is used in the same way as the Spinal page and Extremity page. SpineTech SOAP Help Manual Page 22
Nerves When using the Nerve page Begin by selecting the appropriate button for nerve disturbance (purple button #1 ). Select R-Right, L-Left or B-Bilateral (#2). Select, if appropriate, spinal level demonstrated in #3. The purple buttons at the bottom (#4) are used for further detail as explained in above slides (Right, Left, Medial, Lateral, Superior, Inferior, Proximal, Distal). To the right of the page is a diagram of the dermatones. Select the desired nerve by touching the circle (#5) beside the nerve name. Keep in mind all of the buttons on the page do not have to be used. Only use the buttons appropriate for the patients coindition. SpineTech SOAP Help Manual Page 23
Muscle Tissue The muscle tissue page is used to select muscles in the body that may have weakness, adhesion's, trigger points etc. SpineTech SOAP Help Manual Page 24
Muscle Strength The Muscle Strength page Select the appropriate muscle tested by choosing the pink circle (#1) on the appropriate diagram. Then select the muscles level of resistance (#2). SpineTech SOAP Help Manual Page 25
Exam The Exam page has a list of chiropractic tests (#1). The circles beside the test name (#2) are used to select (-)- negative Test, (+R)-Positive on Right, (+L)- Positive on Left, (+B)- Positive Bilaterally. SpineTech SOAP Help Manual Page 26
Car The car page will come up in the auto accident/personal injury page. It is used to select the impact site on the patients vehicle and the other vehicle in the accident. SpineTech SOAP Help Manual Page 27
Body Direction SpineTech SOAP Help Manual Page 28
SpineTech SOAP Help Manual Posture The posture screen is used to note abnormalities with a patients posture. Select R-Right or L-Left (#1) for the apropriate abnormalities. On the lateral view simply select the pink circle (#2). SpineTech SOAP Help Manual Page 29
Objective Main Page From the main page, when OBJECTIVE is selected, this the screen that comes up. Select the Heading to insert the word "OBJECTIVE " into the note. The Main Horizontal Menu contains Template, Other, Patient Better, Patient Same, Patient worse. (#1) Template- contains templates for different Diagnostic tests including Radiology, Gait scans, ROM scans, Reflexes, sensory etc. In the statement section of each subsection of the vertical menu, you will find lists containing the results of each diagnostic exam used. You can highlight as many of these as appropriate by clicking the circle next to the statement and click the check mark to add them to the note. These can be edited, added or deleted to fit your practice using the edit button. For Example: (#4) If your patient had a 2 view cervical and a 2 view lumbar x-ray you would choose the buttons indicated by the red arrows. You would then click the check mark. (#2) Other- Contains exam, posture, subluxation, misalignment's, etc. This button is used for new patients, changes in patient status, re-evaluation and progress exams. (See Next Slide). (#3) Patient Better, Same and worse contain general statements based on patients condition when the diagnosis remains unchanged. SpineTech SOAP Help Manual Page 30
OBJECTIVE Other As with SUBJECTIVE other, OBJECTIVE Other is used to add more in depth detail about a patients condition. To use this section you start with "Evaluation" (#1). You choose the buttons on the left that are appropriate for the Exam that the patient received and select the results. You then move to the next appropriate section of the vertical menu on the left and select only the buttons you need for the patient. Every patient will be different. For example: (#2) If it is the patients Initial evaluation, they have Subluxations and spasm, You checked Kemp's and Valsalvas, and they have abnormal posture you would choose the buttons indicated by the green arrows. After completing all the sections you need you select the (<) (#3) arrow at the top left of the screen to return to the main note page. SpineTech SOAP Help Manual Page 31
ASSESSMENT Main page This is the ASSESSMENT Main page. You will see the same horizontal menu titles as OBJECTIVE main page. As Before, Select ASSESSMENT heading to insert "ASSESSMENT" into the note. (#1) Template- contains diagnosis packages and groups of diagnosis' separated into Subluxation, Somatic Dysfunction, and Medicare groups A,B, C, and D. There is also an Alphabetical list of Diagnosis. The packages have both ICD-9 and the new ICD-10 codes. They can be edited, added or deleted to fit your practice using the edit button. (#2) Other- Contains More diagnosis buttons, prognosis difficulties with care, MMI, and final assessment. This button, also, is used for new patients, changes in patient treatment, prognosis, exacerbation's etc. (#3) Patient Better, Same and worse contain general statements based on patients condition when the diagnosis and treatment remains unchanged. SpineTech SOAP Help Manual Page 32
ASSESSMENT Other With the ASSESSMENT Other section if you have already chosen a diagnosis in the template section you will not need to use the Diagnosis button. You will begin with Improvement Made. Under Improvement made, you select prognosis. If you are doing a medical massage note, The times for massage are listed here. Like with the other pages you move through the subsections in the vertical menu and when finished use the (<) button to go to the main note page. SpineTech SOAP Help Manual Page 33
PLAN Main Page Navigate the PLAN Main page the same way as the others. Begin by inserting the heading. Move through each horizontal menu selection, using the appropriate vertical subsection menu. The Therapy button is the one I use in day to day notes. I do not use the Other or the Template button except for special circumstances, such as home therapy instructions or referrals. SpineTech SOAP Help Manual Page 34
PLAN Other This button is used for new patient notes. It contains Treatment goals, schedule, consents, and requirements, such as copy's. SpineTech SOAP Help Manual Page 35
PLAN Therapy The PLAN Therapy Section is used for the patients treatment, including manipulation. The Treatment Packages button is used to select treatment packages for cervical, lumbar or full spine, with or with out PT, billed as OMT, CMT or cash patients. There is a massage therapy button for medical massage notes. The Modalities button has a list of PT modalities that your patient may receive. Just like all of the buttons in the program, these buttons can be edited to fit your practice. SpineTech SOAP Help Manual Page 36
Other Buttons on Main Page Email Note Button (#1)- Used to send an email to another doctor or clinic containing the note. Print (#2)- print the note by selecting this button Prior Notes (#3)- Displays a list of all prior notes Appointments(#4)- Displays appointment for this patient Documents (#5)- Displays all documents attached, such as images captured, massage man, etc. Save (#6)- Button is used to save the current note. Always save after completing note. Clear (#7)- Completely clears current note. Same as Previous (#8)- Inserts same PLAN section into current note as was put in previous note. Insert Dx (#9)- Inserts the Dx that was chosen on the add patient page. Visit Details and Signature- (See Next Slide). SpineTech SOAP Help Manual Page 37
Visit Details and Signature The visit details button is to add the patients next appointment into the note. Under next visit choose appropriate day or time period for the patients next visit. Then move to signature. SpineTech SOAP Help Manual Page 38
Signature and Adding Actual Signature The signature button can be programed with many different workers. Program them using the edit button. You can also add a signature using a stylus (See next Slide). This actual signature will be inserted into the final note when the button is chosen. SpineTech SOAP Help Manual Page 39
Adding Actual Signature After choosing the pencil icon at the top left of the screen this is the screen that will appear. On this Edit screen you can: Change the title of the Dr. or therapist in this box (#1). Change the description inserted into the note (#2). Sign using a stylus (#3). SpineTech SOAP Help Manual Page 40
HELP (?) Buttons When using any screen, if you are unsure of the function of any of the buttons, select the (?) button (#1) at the top left corner of the screen. This opens Help mode. When in Help Mode, the screen will turn transparent gray and each button will be explained by highlighted yellow text (#2). To Exit Help mode select the yellow (X) (#3) at the top right of the screen. SpineTech SOAP Help Manual Page 41