Provider Workflow

SOAP Note Documentation
Toggle between the areas of the SOAP note by the “Next” button (upper right-hand corner) or by clicking the next item in the sequence at the top (see below).
Please note: Problem List is completed by providers only.

Imaging & Referral Orders
Imaging and referrals take place through KAPA (Knoxville Area Project Access). Please place a referral to a specialist and choose KAPA as the receiving provider.  If you need to order advanced imaging (MRI, CT, etc) please order this as a referral to Radiology and also put KAPA as the received. After you sign the order, the paperwork is handled by the SMLC office staff.
Lab Ordering
Lab orders can be placed from one of two areas.
(1) The first section is the Diagnoses & Orders menu item on the right side of your screen. The Diagnoses & Orders menu item is a permanent fixture that is accessible from the Review, HPI, ROS, and PE sections of the Exam stage. (2) Lab orders can also be placed from directly within the Assessment and Plan (A/P) subsection of the patient exam.


From the Assessment & Plan section of the Exam stage, search for the appropriate diagnosis. Add the desired labs, then click on the lab order. Then click View More below the lab.

Please indicate Office for lab location and Practice for billing type (Source, Note, Collector, and Time may be filled out by RN).

The order can then be signed by clicking the Sign Orders button in the upper right-hand portion of the screen. This will send the order to the clinical inbox. Great job!

Diagnosis & Order Code
Some ICD-10 codes will populate automatically for diagnoses and orders. If it turns “red” (as below), please click on the red “ICD-10 code,” and select appropriate option. Please note that all diagnoses can be ordered top-to-bottom as you would like by clicking and dragging the dots to the left of the diagnosis.

Below the diagnoses, please indicate return to office date & reason. Patient education materials may be included here or under “diagnoses & orders.”

Before note is finished, please go to “Billing” at the top right side of your screen and input the appropriate CPT code under the box labeled “E&M.” Great work!





Lab results:

• You will find lab results in the inbox for the Provider who ordered the lab.  If you are covering, please check the inboxes for all of the Providers who saw patients that day
• Click on lab and screen below will come up:
  • Scroll down to review all labs
  • Click Select All (top arrow) to write note for all labs
  • Put note you want passed on to the patient in the “Action Note” section (highlighted below)
  • 
    Click “Leave in REVIEW to” and put last name of whoever you want to receive your message (e.g. Nurse Manager, covering nurse, etc)
  • Click “Save” (highlighted at bottom)- the results will then go to the inbox of the person you selected

• Patient Cases are the best way to send a message to our Executive Assistant, Nurse Manager, Medical Director, or covering nurse about a patient.  This is also the way to document a conversation with a patient over the phone.
• To create a patient case:
  • 
    In patient’s chart, click purple box with 3 lines in upper right corner of chart, then click on “create patient case”

• Putting information in patient case:
  • Fill out highlighted fields below- source is who you talked to (e.g. patient, pharmacy, spouse) and type is reason for call
  • Provider: put your own name or Medical Director
  • 
    Subject: topic you discussed on call
• • Case Description: Summarize call and next steps or request for whomever you are sending patient case to
  • If you are summarizing call and have no further steps, click “Data Entry Completed” and then click “Save”

• • If you are sending a task to someone else, choose “Leave in DATAENTRY to” and put name of person you are sending the message to, then click “Save”
  • You can also click “Save and add orders” which will take you to patient chart where you can prescribe medications or send referrals if needed