Documentation

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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 (https://privatepracticehelpdesk.ladesk.com/563767-Patient-Dashboard---Episodes) Click on the drop down option to show all 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...

Patient Portal - Data PrePopulation

Once the patient enters data using the Initiate E-Visit from his/her patient portal, it will be made available to the provider to use during documentation. During the Initial Evaluation documentation, a pop-up box will open automatically. The provider will be given the option to use the data provided in the Initiate E-Visit (by the patient portal). The clinician has the option to check and uncheck different elements that they would like to use. The clinician scrolls down and will be given ...

Subjective Tab - Initial Evaluation, ReEvaluation and Progress Note

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 ...

Subjective and Objective Templates

In In Touch EMR users can create templates for the following section: - Subjective - Objective - Flowsheet - Goals To create any template, users must be in the document section. In this lesson, we will only discuss how to create Subjective and Objective Templates. If you want to review the lesson on how to create Flowsheet templates, click here. (https://privatepracticehelpdesk.ladesk.com/300073-Flowsheet-Tab) If you want to review the lesson on how to create Goal templates, cl...

Subjective - Daily Note and Discharge Note

Daily Note For Daily Note, by default, there is only 1 tab under the Subjective section. But if the Pain Scale on Daily Notes feature has been turned on, 2 sub-tabs will appear under the Subjective Tab: - Default - Pain Scale To review the lesson on how to turn on /off the different features for each user in IN Touch EMR, click here. (https://privatepracticehelpdesk.ladesk.com/163671-Staff---Set-Up---Compliance-) Default Tab Here are all the elements in the Default ...

Objective Section

There are 2 tabs under the Objective Section - Builder - Library Builder Tab This is for users to create their own templates. To review how to create and use Subjective and Objective templates, click here. (https://privatepracticehelpdesk.ladesk.com/970714--Subjective-and-Objective-Templates-) One of the main difference of the Subjective Template Builder with the Objective Template Builder is the Done For You Sections. Template Library Tab This is the list of all created...

Flowsheet Tab

The flowsheet in In Touch EMR is a list of all the procedures and exercises that were performed during the visit and the associated CPT code to charge for each procedure or exercise. Flowsheet Tab - Add New - This is to create a new Flowsheet - Template Builder - This is to create new Flowsheet templates - Preview - When this button is clicked, you will see a pop-up for the Flowsheet preview. In this pop-up, you will see a summary of all the previous flowsheet that was create...

Assessment Tab

The Assessment Tab has 2 text boxes. - SUMMARY OF ASSESSMENT FROM PROVIDER - SUMMARY OF INSTRUCTIONS PROVIDED TO THE PATIENT We want to make it easier and less time consuming for our clients to do their documentation. We have created an auto-complete text feature that will allow you to create short codes and use them in text boxes to have the system automatically add the text values. Users can create paragraphs, sentences or phrases that are more commonly used into a text value ...

Plan of Care

There are several components in the Plan of Care section which will be discussed in this lesson - Medical Necessity - Codes - Types of Services to be Provided - Goals - Instruction/Intervention - Physician Options - Provider Options Minimum plan of care requirements for Medicare patients includes documentation of a primary (physician) diagnosis and therapy (encounter) diagnosis, description of procedures and modalities, amount frequency and duration of services and dat...

The Claim Review Tab

The claim review section is the last tab of In Touch EMR documentation. This serves as a review of what the claim will appear to be in In Touch Biller PRO once the user has finalized the document. The user will have the ability to edit the information in the claim review tab prior to submission. - Refresh - It is very important that users click the refresh button to transfer over the latest information entered in the Subjective, Objective and Flowsheet tab to the claim review section. Fai...

Claim Summary

After the document has been finalized, the claim information is automatically transmitted to In Touch Biller PRO for claim submission. When the document appears in the Patient Dashboard, it will include a dollar sign that will allow users to review what the claim details are for that completed document. A pop-up appears that will show the details of the claim. To make it easier for billers to find the claim details for multiple patients and dates, view the Claim Summary by followin...

Submitting Documents for Review

By default, non-licensed clinicians like PTAs, COTAs are allowed to finalize a note, assuming the rendering provider’s approval is provided and the rendering provider's initials are entered in the system. But when the Rendering Provider Authentication feature has been enabled, this user will no longer be able to finalize any document and generate a claim. The user will, however, be able to use 'Submit for Review' and select a rendering provider. This allows the user to send documents to a rend...

Saving Data in In Touch EMR

How Data Saves in In Touch EMR In Touch EMR Saves Your Data in 4 Ways 1. Save Button The save button is available throughout all the sections of the documentation. - Subjective and Objective section, you will find it at the top and bottom of the page. - Flowsheet section - inside the Flowsheet pop up and it will say “Save Flowsheet. This button must be clicked before exiting the flowsheet. - Assessment section - only one button at the bottom ...

Carry Forward Feature

The Carry Forward Feature in In Touch EMR This unique feature allows the users to copy the clinical record, including Subjective, Objective, Flowsheet, Assessment and Plan of Care to another patient record or same patient to a different document. The principle behind this feature is to save the clinician time when working on the documentation so that the information from the previous note automatically appears to the succeeding notes without the clinician having to retype the whole information...

Summary of Outcome Measures

Measuring health outcomes is central to assessing the quality of care. Outcomes measures can be very useful in quality improvement programs, by pointing out the areas in which intervention could improve care This is the reason why the Outcome Measure is one of the important part of the In Touch EMR documentation. On the Add-on Section, a summary of all the Outcome Measure can be generated. The Outcome Measure page will appear. The users can use the filters providers to search for a particul...

Auto Complete Short Codes

Auto Complete List The auto-complete sentence feature allows you to enter in a short alphanumeric code into your documentation that will cause an entire sentence to populate into the documentation. This will allow the users to save time by not having to type long phrases, sentences, or paragraphs that they constantly use in their documentation. While inside the documentation section, you will find the Auto Complete list of short codes above the main tabs (Subjective, Objective, Flowsheet, ...