making soapnotes: forms
contents
Building the form
Log in or, if you haven’t already, register and you can get started.
Once you’re logged on, you can take a look at some sample forms and calculators by going to this page.
Create a new form
Go to Edit Forms. There you can look through the forms that have already been made and get a sense for what’s possible.
Since you already have a goal in mind, you could just get right to it and make a new Form. There’s a few ways to do this: either click on the “Add New” button near the top or on “New Form” on the “Forms” menu at the left. They both take you to the same place.
Elements of a form
You should see two things: at the top of the form it should say “Untitled Form”. You’re going to edit that to have the info for your form. The only thing you MUST do for this part is put in a title for your form. Give it a unique title that you will remember (or can find easily). The “Description” part is optional, but you’d probably want to at least delete that sample text. Then SAVE the form before moving on.
Making changes to a form (and saving them)
Anytime you save the form, the form builder is going to respond to you with some options after it’s saved it. Usually, the right choice is to click on “Continue editing the form”. But you can always preview it if you’d like.
Getting the form to work
What about “Result Template,” “Calculation Formula,” and “Calculation Result”?
- Result Template: This is where it all comes together. Here, your boilerplate and variables are listed together the way you want them.
- Calculation Formula (optional): This is an optional field that can be used to perform calculations based on values the user enters. This is an important part of constructing clinical decision rules. Unless you’re performing a calculation, you can leave this blank.
- Calculation Result (optional): This is an optional field that interprets the results of the Calculation Formula. You define the ranges for the calculator this can put those definitions into your final output.
If you’d like, you can put your goal output or any random thoughts you might have on the “Scratch Pad”. One caveat, nothing is ever saved in the Scratch Pad. It’s really just an extra workspace I thought would be handy. Don’t put anything in the Scratch Pad that’s important unless it’s saved somewhere else, too!!!
Over at the right, there’s a box that says “Add Fields”. This is for adding your variables to your form. Once you click on one of those, such as “Multiple Choice,” it’ll put that into your form and you fix it the way you like it. You can add as many fields as you like, but it’s probably a good idea to keep it simple to start. And save your work often!
Once you’re done putting in variables and questions for your variables, you can start working on the finished product. So, put together your form with as many questions as you have variables, save it, and then go up to the “Result Template” in the box with the title of your form at the very top.
One approach would be to put your goal output from the Scratch pad (or wherever else you have it) into the “Result Template”. {and then save your work!}
My Approach to building a form
It goes like this:
1. Start with a note.
Here’s a sore throat history, for example:
“Symptoms have been present for 2 days. Patient reports fever, malaise, and swollen lymph nodes. Denies cough, headache, or rash. Intake: normal. Elimination pattern: normal.”
2. What’s boilerplate and what’s a variable?
Variables could include duration of symptoms, and then all of the symptoms (pertinent positives and negatives). Boilerplate is what’s left.
3. What type of field should I use?
The most often used will be the “Multiple Choice” field. But this one will also have “Paragraph Text”, “Number”, and “Checkbox” fields.
Paragraph text is good for allowing someone to put in free text.
Number fields are good for age and duration of symptoms
Checkbox fields are good when there’s a littany of symptoms you want people to check off.
4. Add in other pertinent positives or negatives or other symptoms that weren’t in your original note.
For the reports and denies part, here’s a list:
headache
fever
nausea
rash
cough
myalgias
malaise
swollen lymph nodes
For the intake part, here’s a list:
Normal
Adequate
Poor
For the elimination part, here’s a list:
Normal
Decreased urine output
Diarrhea
Decreased stools
Constipation
5. Keep it loose with enough places for free text.
Add something simple like a free text field for “other symptoms”
Look through it and wherever you find text that relates to a variable, you should put in the form builder’s code for that variable. Once again, this is much easier to learn by watching a demo than by reading. Nevertheless, it should be super easy. What you do is go down the form to where you have the question for a particular variable. Right underneath the title of the field is “(copy)”. If you click on that, then it’ll grab the code for the variable. Next, go up to the place in the “Result Template” where you want to put that variable and put the cursor there. Finally, click on “(paste)” right next to where it says “Result Template” and it’ll put it in there for you.
And then repeat that process for any other variables in your form.
That’s basically it for making a form.
Publish your form
Once you have finished making your form-based template or calculator and you’re ready to test it, you need to publish it. Posting a form makes it active online.
Go to Posts to publish your template. This is where you can keep everything together: the template you just made, background info or highlights, any references or links, relevant patient education, and even a link to the annotated superbill snap (more on that later).
Now you can add your form to a post and publish it. There’s a few ways to do this: either click on the “Add New” button near the top or on “New Post” on the “Posts” menu at the left. They both take you to the same place.
At a minimum, you could just add your form to a new Post, name the Post, and publish it. That goes pretty fast.
To add the form, click on the button that looks like this: 
It’ll ask you which form to add to your Post and then you’re almost done. Click on the “Publish” button and view your work.
Please let me know if you have any troubles with this or suggestions.
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