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.  If you want to review the lesson on how to create Goal templates, click here

Creating Templates 

Subjective 

For the Subjective section, the template creation section is only available for the following note types: 

• Initial Evaluation 
• Re-Evaluation 
• Progress Note

Users will find a builder tab for the note types mentioned above.

To start creating a template, enter the template title and description. Once you click on the Next button new options will appear: 

When the Select a Type of Question drop down is chosen, it will provide you with a list of question type options.

 

Objective 

For the Objective section, the template creation section is available for All note types except a Miscellaneous note. 

Like in the Subjective, you will find a Builder tab. Once clicked, there is also a section for the Template Title and Template Description. 

 

Done for you sections

This is a special feature of In Touch EMR that will provide you with done for you sections. We have based the questions on the requirements of Medicare or most commonly used questions by other providers

Click any of the done for you sections to add a check mark next to that selected item. Once selected, this section will now appear on your template. 

• Cognition -  this done for you section has 4 tabs that once selected will open a text box allowing users to type their entries. 

• Alertness 
• Judgement 
• Communication 
• Memory
• Functional Limitation -  this done for you section is important for Medicare patients. The system will prompt users at the onset of documentation if a Functional Limitation is required. In this section you will see a drop down list of different functional limitation to choose from. 
  

 

Once the user selects one of the drop down options, it will automatically provide the Functional Limitation G Codes (FLG codes) associated with the Functional Limitation selected. When the Objective section has been saved, the FLG codes provided will appear in the Claim Review section of the documentation ready for billing. 

 

Supporting Evidence tabs will also appear after selecting an option from the drop-down. In each of the tabs once clicked, it will provide a text box allowing the user to type in entries. 

IMPORTANT NOTE: The Impairment Rating tab  is a necessary field. The Functional Limitation section will not save until the user chooses an option in the Impairment Rating tab. There are 2 areas that needs an entry, the Current and Goal. It will show percentage options that the user can click one option for each Current and Goal. 

 

• Neurological - this done for you section has 4 tabs that once selected will open a text box allowing users to type their entries. 

• Sensation 
• Reflexes 
• Balance 
• Motor Control
• Cardiopulmonary - this done for you section has 5 tabs that once selected will open a text box allowing users to type their entries. 

• Outcome Measure  - this done for you section is important for Medicare patients. In this section, you will see a drop-down list of different Outcome measure questionnaires. 

If you want to review the lesson on how to use the Outcome Measure in the Objective section, please click here. 

 

Choose Sections 

Back to creating a template, under the Choose Sections, In Touch EMR has provided the most common names for Sections. The users will have the ability to choose the section names under the Available Sections box and highlight the section and click the blue button going to the right. 
The selected section will now appear on the right. 

Adding Questions

At the bottom area of the template creation, you will be able to start adding your questions. 

First, indicate which section do you want this question to appear. The system will provide a drop down of all the sections that you have selected for your template. 

Once the section has been selected, choose what type of question you want to create. There will be a drop down selection of different questions types available. 

Once a question type is selected, it will provide different options for each question type. But the following options will remain the same for all question type:

• Add Goal Box - If this is enabled, In Touch EMR will give the user an option to add a goal associated with this question. A dynamic goal box will appear along with this question. The goal will automatically propagate to the plan of care and will always be 'tagged' to the question. This field can be left empty in which case no goal box will propagate to the plan of care. This is ideal for questions that are commonly associated with goals.

• Add Comment Box -  If this is enabled, In Touch EMR will give the user an option to enter text into a comment box associated with this question.  A comment box will appear along with this question. The text in the comment box will automatically propagate to the PDF document and will always be 'tagged' to the question. This field can be left empty in which case no comment will appear on the PDF.

• Push to Plan - At times, information from the objective section needs to appear on the plan of care. If this is enabled, In Touch EMR will automatically take the question (and associated answer) and propagate it to the plan of care section, enriching the narrative in the plan of care. If this question is ignored / unanswered / empty, then nothing will propagate to the plan of care. This is ideal for questions that are commonly associated with the creation of goals, and in situations where the question (and the answer) need to appear on the plan of care. This helps paint a vivid 'clinical picture' to the referring physician and eliminates the need to send entire notes to the physician for signature.
  
  
• Mandatory Question - Questions can be made mandatory. If this is enabled, the system will require the user to answer that question before proceeding to other sections of the documentation. If data is not provided, that section will be highlighted in red, and blue pop up notification box will appear reminding the user to enter data before proceeding. For ease of identification, these questions will be tagged with a large red asterisk, reminding the clinician that they are mandated during the documentation workflow. This is ideal for questions that must be answered / components that must be documented for compliance purposes. For more details on compliant documentation, call support and request the In Touch EMR compliance blueprint.

 

Different Question Types 

Each question type once clicked will provide different options depending on what that question type will require to create the questions. 

 

• Multiple Choice (Only one answer) - Enter the question on the Question Text and type each possible answer on the text box. When users add possible answers, it will appear on the Question Options. Users can enter as many possible answers as you wish. 

 

The Multiple Choice (Only one answer) questions will appear on your template like so: 

The answers will have a radio button for users to be able to select that option. 

IMPORTANT NOTE: Once this question type has been answered and it carries forward to the succeeding documentations, users may change their answer but it can not be left unanswered again.  

• Multiple Choice (Multiple Answers) - All looks similar as above except, the user is allowed to have more than one answer for this question. The only difference is instead of a radio button, it will have check boxes to mark their selections. 

• Comment/Essay Box - The Comment/ Essay Box Question Type is an excellent choice if you need to enter a narrative question such as a patient's chief complaints in their own words. For this Question you no longer need to choose the add a comment box option because this will already provide a comment box within the question. Type the question and click on Add Question. 
  

 

Once the question has been added, it will automatically have a text box at the bottom for the users to type their answers. 

• Rating Scale - The Rating Scale type of question is perfect for several questions that has the same possible answers. This allows users to add one question with multiple rows with the same possible answers. Users will have the option where you can select the number of ratings. Users can select between 2 to 16 ratings.

You will then be prompted to select a Label and the Weight of the Label.

Only one answer is allowed per row. 

 

• Matrix of Choices (Only One Answer Per Row) - A matrix is essentially a grid of options. So what you will need to do is enter question Rows and question Columns. The columns are the options that you can select for this question. When you are creating a matrix of Choices with only one Answer per Row, you will only be able to select one of the options in the Columns.

 

Only allowed 1 answer per row. 

• Matrix of Choice (Multiple Answers Per Row) - Similar to the above but will allow multiple answers per row. 

Here's how the question will look like:

• Matrix of Drop Down Menu - To create a Matrix of Drop-Down Menus Question type, enter the Question text first. For each Questions the user will be prompted to enter in Menu choices. Users can choose to use the same choices for each Menu or use different Menu choices for each Menu. So fill in the Menu title and the choices for each Menu.

Here's how the question will appear:

• Single Textbox - this question only requires the user to enter the question and it will provide 1 textbox 

The question will appear like this:

• Multiple Textbox - This question allow users to have one question but multiple text boxes will appear. This is good for questions that will require text but 
• Numerical Textbox - This question will show a text box but only numbers are the allowable characters 
• Descriptive Text - This is a headline for a section and not a question. 
• Matrix of Textbox - This question allow users to have a table of textboxes. It is similar on how to add a Matrix of Drop-down, the only difference is you do not need to record the choices.

 

Template Library 

Both the Subjective and Objective section has a template library that will have the list of all the templates that has been created. 

 

1. Search box - This will make it easier to find a template. By typing a word, the system will look for a match and show the list of all the matches of the word/s typed
2. Template list - users will select the template they want to use or perform an action from the list by clicking the template. The system will highlight it in blue once it is chosen.
   
   
    
3. Edit - This button allows the users to edit the chosen template. It will automatically direct the user to the Builder section to make changes. 
4. Duplicate - This will create a copy of the chosen template and name it "Copy of (title of the original template). This is a good way to ensure that the original template is not overwritten. Once the template has been used for previous patient documentation, it can no longer be edited or deleted to avoid any changes to the patient document. The system will provide a warning notifying users if the template can no longer be edited or deleted.
   
   
   
    
5. Share - This allow users to share their template to other users within the clinic. Once clicked, it will provide a notification that the template has been shared successfully. This template can now be seen by all the users within the clinic. 
   
   
    
6. Manage Templates  - A pop-up box opens and allows the users to Activate or Hide a template. This is helpful for those templates that can no longer be deleted because it has been used in the documentation but the user will no longer use it moving forward. To avoid having an overcrowded list of templates and to increase the loading speed of the page, it is best to hide some of the templates.