Making S.O.A.P Notes Easy
The Team
Danny Briggs - Product Manager
Dr. Amy Dietrich - Clinical advisor
Project Details
Length of Project - 8 Sprints
Goal - Create a solution that will help providers decrease time and effort for creating clinical note process.
Ace Ujimori - UX Designer
Understanding
& Research
Identify all the elements of a clinical note.
Identify down stream effects of poorly done notes.
Acknowledge users behaviors and preferences.
Overview
EPMS is the enterprise system that houses financial, clinical, and operational functions of the office.
Each function leads into other areas and will effect other systems such as insurance and accounts receivable.
Opportunity
Clinical notes that are either incomplete or missing insurance companies will often refuse to reimbuse the office.
​
Clinical notes are often seen as a "cover my ass" document. It provides insights into procedures and discussion that occured between patients and providers.
Interviews
Interview where done with doctors and hygienist (included in the term "provider"). Interviewers were asked about when they complete their notes, where they complete them, what details they included vs what was excluded, and when they would need to referance them again.
WHAT PEOPLE SAY
I typically do my notes during lunch, however if we have a really busy they I would do them after we close.
I have a word document with a template I've made to copy and paste into EPMS and fill in the gaps since I mostly do the same proceedures
Since I've the birth of my child I don't stay late anymore so I can help out around the house and see my family. This sometimes results in an avelanche of pending notes
Insight 1
Utilizing workarounds that providers have created like templates and dictation.
Insight 2
Simplicity and speed is key.
Notes need to be done quickly so that they can be done as close to the appointment as possible to maintain detail accuracy.
Insight 3
Insurance often references notes in order to accept or challenge a claim on behalf of a patient.
Design Direction
Solutions should allow users to maintain current behaviors and workflows but allows them to streamline their clinical note creation through the use of modular templates.
Current state
Elements on page:
Provider selection
List of procedure codes from the appointment
Open text area
In order to test our theory we added a template function that allowed providers to upload their word documents into EPMS. We piloted with 10 providers and showed a 96% adoption rate.
This solution still required providers to create their own templates and could not cover more complicated appointments.
Dumb Template to Smart Template
Learning that the codes that providers enter for the appointments there was an opportunity to use the codes to trigger the correct fields for the user to populate.
Once the note is created then its automatically sent as a PDF to the insurance company on file.
Links to images, scans are radiographs that the provider can reference when completing their notes.
Odontogram is extremely familiar to providers so it made sense to allow users to select options within that context.
Showing testing results helps provide insurance companies and dental boards that treatment was necessary and justified.
Common text that will apply to all appointments with the appropriate trigger codes.
Instructions for future appointments and to the patient.
Anesthetics details are often overlooked due to the time it takes to manually enter the information. Here we have shorten it to 2 clicks and 1 key stroke.
All general information that is included on most visits regaurdles of what proceedures are being done.
The Results
Time per note average went from 5-8 min/note average to about 1.5 min/note average
After 2 months in use rejected claims dropped 3%.