Introduction to Clinical Content Setup

For most practices, it is not necessary to edit the Clinical Content prior to going live. You may modify Clinical Content to meet the unique requirements of your practice any time, as you use the system.

Clinicient is designed to meet the needs of all rehabilitation specialties, including physical therapy, occupational therapy, and speech pathology.

Clinicient Insight EMR includes a comprehensive library of clinical content and a robust Clinical Content Management System that allows clinical leadership to customize the content that clinical staff can utilize in clinical documentation. This article provides:

  • An introduction to the Clinical Content Management System
  • Best practices in Clinical Content Management for clinical leadership
  • A suggested structure for organizing documentation content

Note: Before editing clinical documentation content, you must be proficient with the documentation process in Insight EMR.

Clinical Content Management System

The Clinical Content Management System is comprised of Topics and Chart Templates:

  • A Topic is a general set of content that may be used in the clinical documentation process for a type of patient. Think of the collection of topics as a library and individual topics are books in the library. Staff can take excerpts from these books, include clinical findings in the form of some additional text or test results, and create a clinical report
  • A Template is generally a subset of a broader Topic. It is useful to think of Chart Templates as being forms that you can use to document clinical findings. If all of the needed content is not included in the Chart Template, additional information may be added from the Topic (book) to complete the clinical report.

Best Practices

Clinical Leadership

Before learning how to use the Clinical Content Management System, it is important that a core group of clinical leaders are identified. This clinical leadership group will have the responsibility to take input from the rest of the clinical staff and incorporate that feedback.

Working Sessions

The core clinical leadership group should schedule regular working sessions done together as a group. During these working sessions, one person from the group should be in charge of editing Topics and Chart Templates based on feedback from the rest of the group. Changes to clinical content should never be made in isolation. A "divide and conquer" strategy where the leadership group works in isolation on different topics is not advised.

Topics and Chart Templates: During these working sessions, the clinical leadership team should work on Topic organization and content first. Chart Templates may be created or edited after the base topic library modifications.

Organization of Content

Prior to getting together for the working sessions, the leadership group should have an outline of their topic content prepared. A suggested outline format for clinical content is included below.

Structure for Organizing Content

Topics are organized with the following hierarchy:

  • Areas: Documentation topics are all grouped under Areas. Examples of Areas: Subjective, Objective, Assessment, Plan.
  • Categories: First level grouping of documentation items under each Area
  • Subcategories: Second level grouping of documentation items under each Category.
  • Documentation Items: Clinical findings and test results.

Although the topics may be organized in a variety of ways, it will be easier to stick with the organizational structure already included in the system. Here is an example.

Sample Topic Organizational Structure

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