Enter Daily Progress Notes

The following describes how to complete daily progress note documentation for patients who have had a completed initial evaluation, using the Goal Tracker Feature in Insight EMR.

Automatic Copy Forward

All procedures (other than evaluation procedures) and documentation elements that are being tracked as goals are automatically copied forward from the patient’s prior visit to the current visit as soon as the patient is marked Arrived, provided that the therapist has signed off on the prior visit. By default, Assessment, Plan, Procedures, and Summary information will copy forward, however these settings are customizable by your clinic admin.

Updating Procedures

You can add new procedures to the list of procedures performed for the current date. Using the Topic Panel, select the check box associated with the procedure item in the topic tree and the procedure will be added to your visit documentation.

Procedures that were copied forward from the prior visit that are not repeated today must be deleted from the current list of procedures. Select the unused procedure in the visit documentation to highlight the associated procedure in the topic list. Then, clear the check box associated with the unused procedure in the topic list.

Alternatively, if you plan to use the procedure in a subsequent visit but not in the current visit, you can enter "0" into the Minutes field next to the procedure. This will cause the procedure to copy forward to your next visit after sign off, while not billing that procedure for the current visit.

Updating Goal Progression

Goals are automatically copied forward along with the procedures from the prior visit. Goals with red text will fall off of the current visit if not updated, but will show up for subsequent visits.

When current findings on established goals within the chart documentation are updated, those updates will automatically transfer to the Goal Tracker under Current. Use one of the following methods to updates goals from their corresponding chart area (Subjective, Objective, etc.):

  • Left click on the value in red to accept it and/or add free text.
  • Right click on the value in red to choose another selection, if one is available.

  • Alternatively, you can select the goal to highlight it, then choose one or more values using the topic tree check boxes.

Updated Current Findings

Update procedural goals within their respective chart areas, and they will automatically populate within the Goal Tracking section.

Adding Summary Contents and Free Text

Free text comments are available in certain areas of the chart documentation (Subjective, Objective, Assessment, etc.). You can add a Summary section to a Category by right clicking on the Category in the Topic Tree and selecting "Add Summary".

Printing or Previewing Daily Progress Notes

To preview the daily note before signing off, click the Print icon and select Daily Progress Note from the list, as illustrated below.

You can also automatically print or preview the Daily Progress Notes from the sign off dialog box.

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