Entering consistent data for CDM
When you enter a patient's medical history and visit notes, we recommend entering it in a consistent matter that is conducive to chronic disease management (CDM). When entered properly and in designed areas of Wolf EMR, medical history information helps you effectively track and manage important disease factors. CDM SOAP templates enable you to enter data consistently/
Wolf EMR can summarize a patient’s medical history information in disease-specific flowsheets and reports, and generate disease-specific patient care reminders only if you record medical information consistently and in the appropriate areas of Wolf EMR.
Entering problems and medical history
You must document the following information appropriately in a patient’s medical summary:
| Problems | Medication | Referrals |
| Smoking status | Allergies | Lab results |
| Alcohol history | Surgeries |
Adding problems from the SOAP: If you select a coded problem in the ASSESSMENT area of the SOAP form, you can add the coded problem to the problem list of the patient’s medical summary. In the Structured field, click the problem, and then click Add To Problem List.
Quick Entry: If you have a visit note open, you can quickly add information to the patient’s medical summary using the quick entry. Right-click, and choose Quick Entry.
Opening the medical summary: If you have a visit note open and want to view the patient’s medical summary, click the patient banner. If you have the Quick Entry window open and want to view the patient’s medical summary, click the patient’s name.
Non-medication allergies: When you start entering an allergy, the EMR displays a list of matching medications you can select from. If the allergy is not to a medication, continue to enter the allergy without selecting an option.
Lab results: When graphing or viewing lab results, if the EMR shows only some or none of the patient's results, you may have to merge an unidentified lab codes from the sending facility to an existing lab code. See Merging lab codes.
"Cleaning up" problems for optimal CDM
To effectively identify your chronic disease patients for reports and rules, you must add appropriately-coded problems to your patient’s problem lists. Avoid adding problems that do not have an ICD9 code associated.
If problem codes your existing patient data was not entered consistently, you can perform practice searches to find affected patients and then assign problem codes to these groups of patients.
Search for all patients who were billed with the disease's diagnostic code or for patients who have lab results that indicate a disease diagnosis (such as HbA1C results greater than 6.5%, which indicates diabetes) but do not have the coded problem in their problem list.
Then, from the search report, add the appropriate problem code to the problem list of all listed patient. In the search report, click Selection > Add to Problem list and choose the correct problem and ICD 9 code. See Creating new practice searches.
Enter visit notes using CDM SOAP templates
When you enter visit notes for a chronic disease patient, use disease-specific SOAP templates and use the History Builder to enter symptoms. This enables you to later view flowsheets that summarize important disease factors for the patient. You can also pull information such as exam findings into disease group reports.
Wolf EMR provides the following CDM SOAP templates that you can use. The CDM templates structure the SOAP form around current disease-specific guidelines, and enable you to pull visit information into the CDM flowsheets.
Diabetes Mellitus Review
Diabetes Mellitus (BCMA)
Hypertension (CDM)
COPD
CHF (for Cardiac Heart Failure)
Chronic Kidney Disease (CDM)
Depression (CDM)
To enter a patient’s notes into a CDM SOAP template, open a SOAP form for the patient and then, in the Template Search list, click the template you want.
Tip: If the list does not include the template you are looking for, you can configure your WorkDesk to show (or hide) additional ones. From the WorkDesk menu, choose Configure > Configure WorkDesk > Visit Exams tab.
The EMR loads the template in the SOAP form and displays the template name at the top of the SOAP form. For more information about using SOAP templates, see Using SOAP templates.
These SOAP templates are linked to corresponding CDM flowsheets, which enable you to track how patients are progressing over time. See CDM flowsheets.
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