Clinical History Notes & Forms
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Chiropractic offices face an increasing burden of patient documentation, not only for the care of patients but also to obtain 3rd party reimbursement as expected. The first obstacle the doctor and office has is is typically “where do I begin?“
Related articles: Point/Click Soap Wizard Overview (or article search 343)
Where to start…
You actually start recording clinical notes by creating a New Claim for any patient who starts care for a new injury or resumes care after a stoppage of treatment (by choice of the doctor or patient). When you create a New Claim you are defining the Diagnosis (ICD-9) for this patient that will be used for all notes from History to Soap to Outcome, Careplan, etc. In Claim Wizard Page-1 it is important to enter all the ICDs for a claim as soon as possible so that they are available in your Notes.
Claim Wizard Page-3 offers a useful area for clinical data collection for the doctor. The Complaints & Exams are useful for Soap Note collection covered in the Soap Wizard Overview linked in this article. The Chiropractic Notes & Analysis and Medications & Prescriptions text boxes are each quite useful since this info can be viewed (and edited) from TravelCard with just one-click. The Chiropractic Notes – relating to the specific claim – are typically used to document how you treat the patient, including specific procedures & analysis to be performed. This info is “for the doctor” and not meant for printing, referral or submission to insurers. It is used by the doctor to review & remember important treatment related info for the patient while they are actually in the office (waiting room, examining room, treatment room, etc.)
A good way to consider how to use this is simply putting yourself in this scenario: “I am going on an extended vacation and want to put enough info here for a covering doctor to treat this patient several times with full continuity of care and no awkwardness, confusion or change. For example an entry could be:
EMS with patient sitting
Check Blood Pressure
Full Spine adjusting with these restrictions:
* Lumbars adjust prone – not side posture
* Cervicals seated – not supine
The Chiropractic Notes & Analysis has nothing to do with stages of care, reimbursement, evaluation or other arbitrary data contrived ultimately for gaining 3rd party reimbursement approval. It was designed as glance and go info that is crucial to providing Chiropractic patient care in your office by you or any doctor. .
After the Claim you are Ready for Notes
Once the Claim info is saved you are ready to create Notes for the initial visit as well as an optional daily SOAP note. Keep in mind there are many ways to write notes in ChiroPulse and you should take a little time planning the transition from “paper collection” to “electronic”.
It is most effective for the Doctor to work from Patient Tab “Doctor” icons” and/or Travel Card. From Patient Tab, click “History Narrative” to create a clinical note/history for the patient. Each clinical history note is linked to a date, claim, treating doctor and has data collected among one or more history data categories. For each history category there are “flags” where you can input data. The “Flags” use is optional, but very useful for important action items that the doctor wants to see quickly at a glance. In the Patient TravelCard the flags can be viewed across all claims thus displaying high priority clinical items (from perhaps years ago from initial treatment) that can be instantly recalled by the doctor. For example, in the past medical history category a finding of osteoporosis and important mri/x-ray findings or contraindications would be entered as flags.
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First Time Preparation
In the History Editor you can insert data several ways:
- Import Template. This is customized text that was previously stored as a template for future notes. Templates can include text/data for one “history category” (Neurological) or multiple categories (Neurological, Family History, Lab, Past Medical History, Work/Social History, etc.)
- Insert Text (Auto Notes). This is “template” text that is shared between Soap Notes & History Notes. Creating these templates is useful since it can be quickly inserted into new Soap & History Notes.
- Oswestry button
- Right-click [F10 hotkey] patient & claim data insert
- Copy/Paste text from other Windows Applications
Over time, it is quite helpful to create a mix of History Templates and Auto Notes. Think of these as your library of history notes. For example you can have a template for New Patient, Reexam, etc. You could create more specific templates as well such as New Patient – Auto Accident or New Patient – Low Back or New Patient – Neck, etc. The goal would be to have a starting point for patients who fit this category so you can quickly create the note.
One thing we recommend is creating a few History & Soap notes before building an extensive collection of templates. You can create templates from previous notes or notes done outside of ChiroPulse for example having used “Microsoft Word” or a word processor when creating narratives at the request of carriers for continuing care.
When entering a new Clinical History Narrative, you start out with steps#1-3 selecting the claim the note is for, the date and attending doctor who recorded the note (you can have multiple notes for one date). Then press Next to view the History Editor.
Each Clinical History is comprised of info entered in one or more History Data Categories. Think of these as Headers, chapters or sections of your note. Only data categories with data actually printout so unused data categories are ignored. Use whatever category is required for today’s entry and remember the data categories are pre-defined (not changeable) and user defined.
Use the select data category list to pick the category that you want to work with. Note that an asterisk * appears before the name of categories with data. Simply deleting the text will not delete the “category” from that note so use the delete button to remove a category from the current note (categories can always be re-added by simply clicking the category and entering text). When reading use the [<] and [>] button to flip between categories if you like. The setup categories button allows you to add or tweak history categories & change the sort order of the categories in your History Note.
After selecting the Data Category you can input your findings in the “Enter Data” editor. Use the Flags box to enter the “Clinical Flags” data for the category. Flags are action items or high priority data that can be quickly recalled by the doctor (in TravelCard, etc).
There are a few buttons on the History Editor that should be pretty obvious or easy to remember, but lets cover them anyways. Use the Save button to save the note. Use the New button to create a new clinical note and put the editor in “new note” mode. Use the Undo button to revert to the starting point and not save changes. Remember that the Delete button deletes the highlighted data category only. This is a safeguard so remember to delete all data categories to actually delete a History note. You can use the SOAP button to open the SOAP editor or use the Print button to print the selected Category or the entire History being viewed. Remember to Save first before printing. One easy-to-miss feature is the ability to hotkey jump to other windows from the top pull down menu. [Alt] then [h] opens the “Shortcuts & keyboard hotkeys menu on top of the window. From there you will see some other hotkeys that quickly launch a window holding two keys at the same time, typically the CTRL+another button.
Cloning a History
When creating a follow up History note you can use Clone to create a new History based on the one being viewed. Cloning duplicate the selected history note and once cloned it can be quickly edited and modified as the new note. To clone, simply select the history date you want to view, press the [Clone] button and enter the date for the new history note. Press Save when finished editing.
Clone a History Note as follows:
- Select the History to edit from the “Select Entry Date” then press[Clone] button.
- The “History Note – Clone Data Entry” window will appear so enter the date of the new entry & press the [OK].
- Edit each category as necessary and press the [Save] button before exiting the History Editor
Working with History Templates
History Templates allow you to rapidly enter customized text that was previously stored as a template for future notes. You can edit History Templates from the History Editor or Setup Wizard Windows. Shown below is a simple way to create a new history templates from the History Editor:
- Click [edit templates] button to open the History Template Editor
- Enter a Template Name in the “Enter Template Name” box
- Click in the data category that you want to work with
- Click (or tab) into the entry field and type in the necessary data corresponding to this category.
For example, the user might want to create a template for Cervical ROM which lists each of the cervical ROM’s but leaves their corresponding values blank. This would allow the user to only have to type each patient’s actual ROM when performing an examination instead of retyping all of the CROM’s on each patient. See the instructions below for importing a history template. - Optionally click in the flags box and type in any flags you might want to have in the template.
- Press Save then exit when done
Inserting Data into History Notes
As mentioned above, in the History Editor you can insert data several ways. Lets go into a little more detail for each method. After inserting text continue editing & finish the note. You can do this using any of the “inserting data” methods shown here.
Import Template(s)
While editing a History note select press the [insert template] button to view the History Multi-template selector window. You can filter (view specific) templates using the “show templates only for this type” dropbox. In box #1 click a template to review it then double-click or press Enter to queue up the history to insert. The template that is ready to insert will now appear in box #2. Repeat selecting templates from box #1 and when done press #3 “Insert templates into note”. Note that before inserting you can also use the “preview selected template text” tab to view what is selected. After inserting text into a History Note, you will find data in the one or more data categories where template text was used.
Insert Text (Auto Notes)
To insert text you must first select the data category the text is for. Now simply click “insert text” and the AutoText editor will appear. Simply select the text block to insert and press “insert text” to return to History. After inserting text into a History Note you will find data in the the category you were working.
Right-click [F10 hotkey] patient & claim data insert
You can quickly insert all patient data or all claim data while composing a note. In addition the popup menu allows you to insert patient or claim info such as ICDs or patient age. Use F10 key while typing to popup the menu and then use the up/down & enter keys to make your selection to avoid having to reach for the mouse. Note that future appointments & posted visits/charges appear here to bolster your note.
Oswestry button
You can insert Oswestry Low Back and Neck index findings & scores from here. Simply fill out the form (or let the patient do it in safe tablet mode) and insert the note. Once inserted you can freely edit the findings.
Copy/Paste from other Windows Applications
Use the standard CTRL+V to copy any text from other applications into the selected text box. Alternately you can right click (or [F10] hotkey) and select “paste” from the popup menu. Note that pictures/graphics cannot be inserted and all text pastes as plain text without text formatting, bold, underlining, etc. This allows the text to be searched and indexed in ChiroPulse.
How Do I Use Less Paper or go Paperless?
Even in today’s modern office some paper must be handled and cannot be avoided. The goal is to minimize redundant paper storage and get all or most of the Patient File from paper to your computer and accessible with ChiroPulse.
We highly recommend a network scanner (or multi-purpose printer/scanner combo) that can copy/scan PDF files directly to your network. Then when you scan a document it’s saved right to your computer network, ready to import/tag. This equipment is relatively affordable and perform well (two sided duplex scan, etc.) to handle forms or reports that a patient might bring in for example upon initial consult. Instead of filing the paper in a chart you scan then import/tag the document to the patient so the info is instantly retrievable. Scanning EOBs is another good example where you cannot avoid handling paper but you can avoid storing paper. Simply scan EOBs and tag/index them for instant retrieval.
You can really cut back on paper by receiving faxes (where you can obtain medical reports, mri, xray reports, etc.) electronically and automatically saved to PDF (instead of printed) . This can be done via software or better yet web-based from services such as myfax.com and others who offer fax send and receive.
Related article on ChiroPulse Document Indexing & Management here:
http://chiropulse.com/blog/?tag=document-management
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