Enter an Initial Evaluation

Chart templates are pre-configured documentation forms that have been created for various patient conditions. Chart templates may include specific patient history, clinical tests, measurements, results from functional assessment tools, an assessment and treatment plan, and typical procedures performed. The template can be loaded for a patient's visit prior to entering documentation results. Using a chart template allows you to quickly and easily enter patient information such as test results, measurements, notes, and so on without having to manually add each item to the patient's chart.

Be sure to review Document Evaluation Complexity for information about complexity-based eval codes.

How do I select a chart template?

  1. Log in to Insight EMR.
  2. From the Chart tab, use the Staff, Client, or Unsigned subtab below the calendar to select the visit to document. Right click on the appointment to Arrive the patient and begin charting.
  3. Click Chart Template and select the template you would like to use.

    Here is an example of a template:

Components of a Chart Template

Chart templates can include the following things:

  • Required items - Anything highlighted yellow on a template is required. You will not be able to sign off on the chart until required items have been completed.
  • Non-required items - Items not highlighted are not required. If you determine the item is not needed, ignore the item and do not make any changes. The system automatically removes the item from documentation when you sign off.
  • Placeholders - Brackets highlighted in blue (<< >>) are placeholders.
  • Default results - Some placeholders include default results for an item.

Ways to Enter Clinical Results

Regardless of whether the item is required, a place holder, etc., there are two ways to enter or modify clinical results on the template.

  1. Left click to accept the default goal result. Double clicking on the result highlights the results and allows you to manually overwrite the result with free text.
  2. Right click to display a list of results and select the appropriate result.

Entering Numeric Results

You can enter numeric results with a right click to open a number pad, but it is easier and faster to use your keyboard to quickly enter numeric results. After entering a measurement, press the Enter key to move to the next measurement.

To accept the default measurement, press Enter twice:

Note: If an item on the template is not needed for your patient's evaluation, ignore it and the system automatically removes it from the chart when you sign off (see illustration below).

Adding Measures Not Included in the Chart Template on the Fly

If a test or measurement needed for your evaluation is not included in the template, you can use the topic tree to manually add what is needed.

  1. If you are measuring a different part of the body, optionally click to select another anatomy and click OK.
  2. Click Filter or Search to find the topic or measure you would like to add.
  3. Double click the item to add it to the patient's chart.
  4. Enter measurement results as needed using the guidelines provided earlier.

Setting Goals

As you are entering or updating results, you can right click and select Make This a Goal on any test or measurement to set the item as a goal. The system automatically adds this to the goal tracker grid at the bottom of the chart.

You can also set goals by clicking directly on the gray star to the right of an item within the topic tree, after you have added a value for the item.

Note: Once you make an item a goal, that goal and its value will be added to the Goal Tracker at the bottom of the chart note. All goals will carry forward in the chart so that you can update goal progress each visit.

The Current column automatically includes measurement result you indicated previously.

To establish a goal, click and select type clinical findings in the Goal column.

Sign Off

Once you are ready to sign off on the patient's chart, simply click Sign.

Tip: Best practice is always to sign off within 24 hours of the visit, and sign all visits in chronological order.

INSIGHT automatically:

  • Checks for completion of all required documentation elements
  • Aggregates units and charge codes based on the clinical documentation
  • Applies billing rules to meet payer requirements
  • Captures and validates all billable time
  • Reconciles procedure time against the length of the visit
  • Allows you to preview and fax a report to the referring physician

Note: You may get additional Medicare related prompting at sign off if you are seeing a Medicare patient. Be sure you have added a Plan of Care to your documentation.

Related Links:

Fax Clinical Reports at Sign Off

Create Chart Templates from Documentation

Document Evaluation Complexity

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