Subjective Tab - Initial Evaluation, ReEvaluation and Progress Note

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Under the documentation section, there are Subjective, Objective, Flowsheet, Assessment, Plan of Care and Claim Review tabs. 

In this lesson, we will discuss the following: 

  • different tabs under Subjective section for Initial Evaluation, Reevaluation and Progress Note
  • define each function of the sections in the Subjective. 


For Initial Evaluation, Progress Note and Re-evaluation, there are 3 sub-tabs under the Subjective Tab

  • Default - this is the template provided by In Touch EMR. This is general across all users. 
  • Builder - this tab allows users to create new Templates 
  • Library - this tab will list all the existing templates allowing the user to choose one to use 

Default Tab

The Default tab is the template created by  In Touch EMR that is general to all users. All users are provided with the same set of questions despite the classification. 

For Initial Evaluation, Progress Note and Re-evaluation, the Default tab will have the following sub tabs:                

  • Preliminary Details 
  • Current Status
  • Previous Status 
  • Pain Scale 
  • Medical Background 
  • Medical History 
  • Recommendations
  • Medications 
  • Body Mass Index
  • Transfer to HealthVault 

Users have the ability to remove the Medical Background, Recommendations and Transfer to HealthVault tabs by turning on the Hide Non-Rehab Subjective Components feature.  To review the lesson on how to turn on /off the different features for each user in IN Touch EMR,  click here.

Important NOTE: For Initial Evaluation, Progress Note and Re-evaluation, the following are necessary fields which means that the Subjective section will not save unless these fields have an entry: 

  • Related Appointment 
  • Primary Diagnosis (Only required for Medicare patients)
  • Encounter Diagnosis
  • Chief Complaint 
  • Current Functional Status 
  • Current Functional Limitations
  • Patient Function Prior to Injury

This is to ensure that all users are following Medicare guidelines and in compliance.

Each time that the users try to click save and one or more of the necessary fields does not have an entry, it will show error notifications. One will be on the upper left hand of the screen and the other right below the sub tabs. The error notification will show which necessary field was not filled out. This will continue to appear until the user had completely provided entry to all the necessary fields. 

The user has the ability to turn on the Mandatory Override feature that allows In Touch EMR to still save the Subjective section entries even if not all of the necessary fields has an entry. It will still provide the error notifications and allows the client to save the documentation. Although it will not allow the user to finalize the note. It will prompt the user under the claim review section that there are mandatory fields that needs to be completed prior to finalizing the document. To review the lesson on how to turn on /off the different features for each user in IN Touch EMR,  click here.

 

Preliminary Details 

Users will see the following fields in the Preliminary Details tab:

1. Related Appointment - If the user clicked the appointment from the calendar and created a document, the related appointment will automatically populate the date of the appointment that the user clicked from the calendar.  Here's what it would look like when an appointment has been selected or pre-populated.

  • In the instances that the user wants to change the related appointment that auto-populated, click on the appointment and a pop-up will appear for the user to choose the appointment from the drop-down selection. Then click on Update Appointment to save the changes.  

 

  • If the user was able to get to this patient chart and started documentation not through the calendar, the user must manually choose which appointment to document.   Click the drop-down selection and the list of appointments will show.   
  • Non-billable Appointments -  when selected, this documentation will not get billed (the claim detail will not come over to In Touch Biller PRO). If you turn on the Ignore Non-Billable Visit Count feature, the non-billable visits will no longer be part of the visit counts. This is specifically helpful since the Progress Note, Re-evaluation and Physician Certification alerts base their count down on the number of visits already created.  To review the lesson on how to turn on /off the different features for each user in IN Touch EMR,  click here.

 

2. Start of care - This is the first time the patient received treatment. In Touch EMR automatically pre-populate this information with the date of when the Initial Evaluation was started. But there are instances where the patient had switched clinics and had received treatment from a different clinic prior to this Initial Evaluation. In these cases, the user has the ability to change the Start of Care Date by clicking on the calendar icon. A pop-up of a calendar will show, select the date. 

3. Visit Start and End Time - These fields are automatically populated with whatever hours was indicated on the date of appointment selected. If Non-billable appointment is selected, you need to manually enter a visit start and end time. Once clicked, a pop-up box will show the hours and minutes indicating the first part as AM and the other half as PM. 

4. Visit # - this is automatically populated based on how many previous documents created on the account. Note that the visit count is specific to the episode. It will not count the visits in other episodes. It will also reset during Initial Evaluation, it will start back to Visit #1. 

5. Date when first reported and nature of symptoms - This is the onset date of when the injury or pain occurred.

6. Nature of symptoms -  this will provide users options to describe the symptoms

  • Acute
  • Chronic
  • New Injury
  • Absence of prior history of injury

7. Primary Diagnosis - This is a necessary field for Medicare patients. This selection indicates the ICD-10 code that may have led to the need for skilled therapy services. It is most commonly specified by the referring provider. This ICD-10 code is closely related to the therapy treatment plan. 

For all Medicare patients, In Touch EMR requires that one or more ICD-10 codes be entered in the 'physician diagnosis' field in the subjective section. An error message will appear if this field is empty. Users can turn on the Medicare ICD-10 override option to no longer require an ICD-10 code to be entered in the 'physician diagnosis' field in the subjective section for Medicare patients.  To review the lesson on how to turn on /off the different features for each user in IN Touch EMR,  click here.

 

There are several important components under the Primary and Encounter Diagnosis: 

1. Search ICD-9 - There are some payers that still requires ICD-9 codes, so this option is still provided. If you wish to remove this option, you can turn on the ICD-9 Disable feature.    To review the lesson on how to turn on /off the different features for each user in IN Touch EMR,  click here.

2. Add ICD-10 - To choose an ICD-10, you can click this option. 

3. ICD-10 - This will list all the ICD-10 codes that have been chosen 

4. Delete Icon 

5.  Copy Icon - once clicked, the system automatically copies the ICD-10 selected from the Primary Diagnosis to the Encounter Diagnosis. This will be helpful to save time so that the user do not have to look for the same ICD-10 code again under the Encounter Diagnosis.  

8. Encounter Diagnosis - This selection indicates the ICD code selected by the therapist, for which therapy services were rendered. The ICD 10 codes selected here will be the ones appearing on the claim. Please check your state practice act, since some states may not allow the therapist to designate this code.

 

Choosing Diagnosis Codes

To choose diagnosis codes, click on the Add ICD 10 button

The ICD list pop-up will appear. There are 2 tabs available 

  • Global - This will have all the ICD 10 codes based on the American ICD-10 and ICD-10-PCS medical billing codes.
  • Favorites - this is the list of ICD 10 that the user selected as the most commonly used or favorite codes. 


First, search for the ICD 10 code, you have an option to type the code.  NOTE: There are no dots/period on the code (e.g. R269) Or you can also search using the description box. You can type a word on the description box and this will show you a list of matches with that word or phrase on the description. 

 

To add the code to your documentation click on the ADD button on the right. 

You will notice that the Add button sometimes has a red color. These indicate  truncated / invalid / unspecified codes.  It is still available but we are highly discouraging that you use it due to possible clearinghouse or payer claim rejection. 


In Touch EMR now displays a 'flag icon' next to the code and the 'Add' button in red for over 4000 unspecified / truncated / invalid ICD-10 codes, alerting the clinician that these codes can lead to the clearinghouse and/or payer rejections.
 

Adding to the Favorites list 

 The favorites list makes it easier for users to search for their most commonly used codes. It will minimize the time to have to look for the ICD 10 code in the Global list of codes. 

In the Global List tab, you will see a star button next to the ICD 10 code, when clicked, this will provide a pop-up notification indicating that the ICD 10 code has been added to the Favorites list. 

This notification appears on the upper left corner of the screen. 

In the Favorites list, the users will have the ability to do the following: 

  1. Delete button - this is to remove the ICD 10 from the Favorites list but will still appear on the Global list. 
  2. ICD 10 Code
  3. Edit Description -since this description will appear on the patient chart and Plan of Care, you will be able to make changes to the description by clicking the edit icon. A pop-up will appear wherein the user can type the desired description and click on save. 

.

4. Add Button - to add this ICD 10 to the current documentation. 


Here's the rest of the fields at the bottom of Subjective Tab 

9. Smoking Status - Users can choose the following selections from the drop-down box to describe the patient's smoking status. 

10. Patient Characteristic - This field describes a further description of the patient's smoking habits

11. Dates - this indicates the time period that the patient was an active smoker.  

12. Laterality - users have the ability to choose N/A, Right, Left or Bilateral

13. Documented Reason for Referral - yes or no question

14. Does the patient have a history of falls? - yes or no question 

15. Surgical Intervention Date - to indicate the date of the surgical operation 

16. Surgical Intervention Type - to list and describe the surgical operation performed

17. Acute InPatient Date of Discharge - to indicate the date of the discharge when the patient was hospitalized

18. Name and Address - Name of the hospital and address

 

Current Status 

The second sub tab under the Default section of the Subjective Area is the Current status. Under this tab, you will see the following fields: 

 

  1. Chief Complaint - this text box is part of the necessary fields. The user must indicate what the patient mentioned as their complaint 
  2. Dynamic Goal Box - This button when clicked opens a pop-up that allows users to fill out the goal box and it will automatically appear on the Plan of Care section 
  3. Mechanism of Injury - this should be a description of the injury
  4. Current Functional Status -  this text box is part of the necessary fields. This text box is for the user to indicate what is the status of  the patient's functions 
  5. Current Functional Limitation  -  this text box is part of the necessary fields. This text box is for the user to indicate what are the limitation in movement or functions. 
  6. Functional Deficit Affecting - this is indicated with a yes/no question. But if yes has been selected, it opens a new section for the user to indicate which part has been affected. 

 

Previous Status 

The third sub-tab under the Default section of the Subjective Area is the Preliminary status. Under this tab,  you will see the following fields: 

  1. Prior Concerns / Symptoms - any other previous complaints / symptoms that the client had 
  2. Patient Function Prior to Injury  - patients state of function before the injury 
  3. Factors that cause an increase in Symptoms  - anything that causes the patient to experience more pain or symptoms 
  4. Details of Work Status - If the option Available has been selected, a pop-up box appears for the user to fill out the information. 

 

 

Pain Scale 

The forth sub tab under the Default section of the Subjective Area is the Pain Scale. Under this tab,  you will see the following fields: 

  1. Uncheck All - If there is any information that automatically carried forward you can remove the entries by clicking this field
  2. In the worst Case Scenario 
  3. In the current Scenario 
  4. In the best case scenario
  5. Nature and Character of Pain
  6. Location of Pain 

 

Medical Background

Each section listed has an Add New button for users to enter new information. 

A pop-up will show that will allow users to select the information to add from a drop-down selection. 

Once the information has been added, it will appear on the section 

 

 

Medical History

There is a list of the most common medical issues that the users can put a check mark on the ones that the patients have experienced or a close family member has experienced. 

Once the tick box for an item has been selected, it will provide a text box. This allows the user to add notes.  

 

Recommendations

Choose from the drop-down selection which best describes the provided recommendations for the patient 

 

Medications

Choose any of the medications by clicking the options provided. 

Once the tick box for an item has been selected, it will provide a text box. This allows the user to add notes.  

 

Body Mass Index

Once the Weight and Height are entered, the BMI is automatically computed and populated. 

Once the Systolic and Diastolic Pressure is entered, there is a bar under that lets the user know if it is within the normal range. 

Transfer to HealthVault

 

Builder Tab

Users have the ability to create their own templates by going through the builder tab. To learn how to create templates please click here.

Library

All templates created will appear on the Library section.

Users have the ability to choose which template to use in their documentation by highlighting the template. It will change to a blue background color once chosen.

Once the template has been selected, the permanent questions will appear before the actual questions entered by the user on that template. 

The highlighted areas on this screenshot are the permanent questions. 

IMPORTANT NOTE:   Even if the user used a template to create the Subjective documentation, the necessary fields needs to be provided completely before the system provides a successful notification that it has saved the document. 

 

 

 

 

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