Introduction to Clinical Documentation
The following is an overview of the clinical documentation process.
Clinical Documentation Process
After patient demographic information and Case information is entered in the system, the patient is scheduled for an appointment with a therapist. Clinical documentation for a Visit is entered by the therapist. The clinical documentation record for initial visits and follow up visits will normally include:
- Clinical services provided
- Subjective information, including information gathered during a patient interview as well as the results from condition-specific questionnaires or scales.
- Objective information, including clinical tests and measurements
- The therapist's Assessment findings
- Treatment Plan, including frequency, duration, and goals
In addition, the information may include the following at the therapist's discretion:
- Goals that are automatically tracked for progression on a visit-to-visit basis
- Any supplies that are dispensed and billed to insurance
- Letters to patients,insurance companies, and other interested parties