Documentation Section

Initiating a Document

To start a documentation, you need to choose the Episode to document in. All patient chart is provided a default episode.  To review the lesson on how to create and edit episodes, click here

Click on the drop down option to show all the list of episodes  under the Document and Episode Section. Choose the episode by highlighting and clicking. 

Once an episode has been chosen choose the type of document. Click on the Initiate Document drop-down and choose from the list.

For new episodes, without any prior documentation, the only option available is an Initial Evaluation and Miscellaneous note. It has been designed this way to pattern the documentation sequence wherein in each new patient care, you need to start a new Initial Evaluation. 

NOTE: If you have recently opened a chart for this patient but have been treating the patient prior to using In Touch EMR, you will need to use a different type of document than an Initial Evaluation. But granting that this is a new patient chart/ episode, then you do not have that option. You will need to open an Initial Evaluation first before you will be able to start creating the other document types. You are not required to finalize the Initial Eval prior to creating other document types. 

Once there is an Initial Evaluation has been opened, the rest of the other document types will be available in the drop-down option. 

 

Documentation Section  

Once the user has chosen the type of document, it will open to the documentation section of In Touch EMR. 

You will notice that it follows the SOAP format. These are the main tabs in the documentation section:

  • Subjective 
  • Objective 
  • Flowsheet
  • Assessment 
  • Plan of Care 
  • Claim Review

Each note type will have these main tabs but it will look differently for other note types. 

 

Adding a Title

Inside the documentation section, you will be able to create a title for your document. In Touch EMR automatically provides a default title for all documentation, it is the type of document and date of appointment (e.g. Initial Evaluation 05/13/19)

But once the user has added a document title, it will change the title to the type of document and title. 

The document title will appear once you view the document from the list of Documents in Progress or completed documents in the patient dashboard. This will help distinguish each document once you have many other documents of the same title. 

 

The episode title shows right next to the document in progress bar (note type- Episode title). This will help the user identify for which episodes the note is being created for.

Note that the Episode title will only be available for the following note type; Daily, Progress, re-evaluation, and Discharge Note.

 

The Episode title will show the following: 

  1. Document/Note Type
  2. Episode Title
  3. Date of Service

 

Progress Rate

Each document will have a progress rate indicator. It is located below the episode title. This will let the user know how far along has been completed in the documentation. 

 

Other Available Options 

Inside the documentation are below the Patient Dashboard Tabs and right next to the carry forward feature, you will see more options represented by these icons. 

 

  •  - this icon when clicked will provide a pop-up notification regarding the carry forward. 
  •  When clicked (like all PDF icons within EMR), this PDF icon will automatically open a page providing you all the information that has been entered so far in this document in progress.
  •  - this globe icon represents the Global scroll feature. 
  • - this carry forward icon allows users to choose a patient and document that they wish to copy information from to be carry forward to this document in progress.
  • - this icon deletes ALL current information on the document in progress. Useful when the system automatically carries forward information from the previous note but the users want to start with a fresh document without any information yet. 

 

Auto Saving Feature

In Touch EMR created a feature for it to automatically save the information that has been entered by the users in the documentation every 5 minutes. To get this feature, you will need to contact your account manager. 

Once the Auto Saving feature has been activated, it will provide notifications every 5 minutes whenever it is saved the document and let you know the time it had saved. 

We still encourage users to click on the save button whenever they have completed a section to ensure that all entries have been saved. 

 

The floating SOFAPCD buttons 

On the upper right-hand corner of the screen, you will see these colorful SOFAPCD buttons. 

These buttons once clicked automatically saves the information that was entered in the current page that the user is on and jump into the corresponding page of where the button is designated to go. 

  • S - Subjective
  • O - Objective 
  • F - Flowsheet
  • A - Assessment 
  • P - Plan of Care 
  • C - Claim Review 
  • D - Dashboard  

Note: For the Subjective area, the necessary fields need to have entries before it saves the documentation unless the Mandatory Override feature has been turned on.  To review which are the necessary fields in the Subjective section, click here.