The Dream Template is a tool being developed by a health center's Clinical Practice Committee to standardize patient documentation and ensure complete data collection for reporting requirements. The template incorporates elements for the subjective, objective, assessment, and plan components of a patient encounter, and includes features such as clinical guidelines, screening tools, billing functions, and patient education materials. Successful implementation of The Dream Template is expected to improve quality of care, reimbursement amounts, and revenues by facilitating consistent documentation across all patient visits. A team including physicians, nurses and quality staff will develop and test the template, with the goal of creating an efficient documentation process that meets the needs of clinicians and reporting obligations.

1. The Dream Template
June 26, 2016
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2. Health Center
Information Systems
HCMT 523-81
Course Project Presentation
June Onorato
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3. Objective
The Dream Template will provide a tool for primary care practitioners that will
encompass all necessary data elements for health center reporting
requirements, while ensuring that all patients are provided with the same
level of quality, standardized care throughout the organization.
Upon successful implementation of The Dream Templates into clinical
workflows, it is the expectation of the health center’s Clinical Practice
Committee that the documentation prepared by incorporating this tool into
everyday practice, will provide an additional benefit of ensuring current
procedural coding for optimal reimbursement and improved revenues.
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4. The Team
Clinical Practice Committee
representation
Physicians and mid-level
practitioners
Nursing and medical assisting
staff
Quality committee
representation
Quality reporting specialist
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5. Fundamentals:
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6. Explicit
knowledge
CDSS alerts,
evidence-based
guidelines
Implicit
knowledge
What is known, but
unspoken or
undocumented?
Latent
knowledge
What have we learned
from caring from
specific individuals?
Tactic
knowledge
What strategies have
been effective in care
delivery?
Putting it all
together
Incorporating a tool to
bring this all together:
The Dream Template
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7. The Structure of the S.O.A.P. note
Populating from the demographics
screens:
Method of delivery of care plan (ie. Patient portal or
paper copy)
Circle of Care providers
Other clinicians and specialty
Family or other personal caregivers
Guardian or other
Marital status, number of marriages
Veteran status
Migrant, seasonal, farm worker status
Occupation
Living arrangement
Primary language
Advanced Directives
Drop-down for status
Problem-focused visit
SUBJECTIVE:
Chief Complaint including
● Brief description of patient, including age and
affect
Patient’s quote of reason for the visit
Past Medical History
Mental health/substance abuse (or none)
Disease or significant health problems
Hospitalizations/surgeries
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8. S.O.A.P. note continued
Link to obtain external Rx history through
HER
Link to Vermont Prescription Monitoring
System to determine narcotic
prescriptions, if any
Allergies/side-effects (or none)
Age appropriate screening test statuses
Reproduction status of family planning, sterility,
contraception, menopausal state
Family History of M/F/S/B/C/A/U including
Mental health/substance abuse (or none)
Disease or significant health problems
Habits
Education
Career
health
Barriers to care or achieving goals, as
perceived by the patient
Self-Management activities:
History of Present Illness including
severity
duration
treatments tried to date and response
patient’s perception of illness/condition 8

9. S.O.A.P. note continued
Clinical (ie. nurse, MA) Staff sign-off:
Statement verifying “the above information has
been obtained by me and has been
documented per the patient’s history and
verified by the patient on this day”, with a
drop-down to select name of clinical staff in
attendance
OBJECTIVE:
Vital signs
In-house tests performed
Link to direct user to billing for these
services
Assessment of physical appearance, affect, distress
or other pertinent observations
Physical examination by pre-populated structure
Problem focused examination with descriptive
blanks
Link to age appropriate developmental tool
Link to condition appropriate screening,
assessment or diagnostic tool
ASSESSMENT:
Link to Evidenced-Based guideline selections by
disease or condition for patient information
Diagnoses, signs, symptoms by ICD-10 code to
appropriate specificity
Comment section as to the above, if any
PLAN:
Tests to be ordered, including requested timing
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10. S.O.A.P. note continued
Follow up plan of care
Link Rx education for new medication prescribed
(tracks in background); printed at check-out
Link Patient education materials related to new
onset of disease, management of symptoms
(tracks in background); printed at check-out
Self-management support (structured links to
specific supports, free-text otherwise)
Link to appropriate community resources, free-text
for comments
Link to website for access to Vermont Ethics
Network for information and tool to create
advanced directives
Button to activate assessment of appropriateness
of care plan based on evaluation
Button to activate audit of entries in mandatory
structured data fields
Billing
“Code correct” assessment of appropriate
CPT code for visit
Clinician selection of code most appropriate
Link to patient PIN code entry to verify care plan
explained, understood and acknowledged, and
list of materials provided, and written
Clinician sign-off to attest to note section to
describe reason for exception to evidence-
based guidelines, or to reflect no exception
needed
Documentation and authorization to
publish visit summary by selected
method 10

11. The Check-out process:
Upon check-out, the front office staff will:
Link to fast-track enroll in Patient Portal
Schedule tests or referral appointments as
documented in the progress note (or indicate
the status of scheduling and follow up)
Schedule follow up visit per clinicians instructions
Collect and document receipt of payment for
services rendered
Button to activate visit summary/care plan delivery
by method selected above; to include
Other hand-outs generated in the note
above (ie. Patient Education, Rx
education for new drugs
Use of The Dream Template will ensure compliance
for program participation for incentive payments,
proper documentation for FQHC UDS reporting,
PCMH reporting compliance and other quality
assurance activities.
A PDSA will be developed to evaluate the use,
effectiveness, efficiency and appropriateness of The
Dream Template and changes and improvements will
be made based on the findings. The clinical staff will
be engaged in the entire process, including revisions,
until a final product is approved by the team and
acceptable to the Clinical Practice and Quality
committees.
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