Document Complex Patient Cases

The following topic compares how both a non-complex case and a complex case are documented in Insight.

Documenting a Non-Complex Case

When documenting a less complex case, you should select one specific topic. The following steps generally describe documenting a less complex case:

Simple Simon has been referred for tennis elbow. He is otherwise healthy. Create a basic single case:

The front desk staff enters any pertinent medical precautions during patient registration.

The case summary in documentation alerts the therapist about any precautions entered in the patient's case.

Select Right Elbow on the anatomical model before entering documentation results.

As you enter information in the evaluation, it is grouped by the selected anatomical area.

If no anatomy is selected prior to entering results for documentation items, those test results are grouped under Non Specific. There will not be an automatic Right/Left Comparison for extremity test results.

You may need to change anatomical areas during documentation. For example, you may include documentation to rule out cervical spine pathology for a patient presenting with lateral elbow pain. Prior to documenting the test results used to rule out cervical spine pathology, you should select the neck area on the anatomical model. If you select specific anatomical parts prior to entering test results, results are grouped anatomically and extremities will have an automatic Right/Left comparison.

You may also change the anatomy after results have been documented by right clicking on either the black or blue header and selecting Change Anatomy.

There may only be one Long Term/Functional Goal for the less complex case, as illustrated here.

Documenting a Complex Case with Medical Syndrome and Multiple Medical Problems

General Payne has been diagnosed with chronic pain and depression. He is overweight, sedentary, deconditioned and has had a recent cardiac artery bypass graft.

You may elect to enter a free text summary under Subjective for a more complex patient as illustrated here:

Yellow areas in this evaluation were entered with free text.

You may include general screening notes in the Objective area of the documentation as illustrated here with free text entered comments highlighted in yellow:

Here is an example of organizing documentation using functional levels rather than clinical test results to track goals:

Click here to move×