Launch Clinical Documentation

In this topic, you will learn the steps needed to begin clinical documentation for a visit using Insight EMR.

Background

Insight EMR is an integrated system for scheduilng, clinical documentation, billing and financial management and supports a defined workflow.

  • Patients are registered prior to scheduling an appointment. The patient's legal name, date of birth and gender are all required for scheduling.
  • After the patient has been scheduled for an appointment, the Appointment Status must be changed to Arrived before therapist may begin documentation. A patient Case along with a primary diagnosis are required before the clinician may initiate documentation.
  • After the clinical documentation for the visit is complete, the clinician can electronically sign off on the documentation. In addition to the above information, the insurance information or guarantor for the Case must be entered prior to sign off.

This workflow for patient registration through the sign off on clinical documentation for a patient appointment is illustrated in the following table:

Workflow Step Minimum Information Additional Requirement
Patient Registration Patient Name, Date of Birth, Gender None
Patient Scheduling Appointment Time and Appointment Type None
Start Clinical Documentation Case and Primary Diagnosis Appointment Status Marked Arrived by front desk or clinician before beginning documentation. Clinician will be prompted to select the Case if the patient has more than one active Case.
Sign Off Clinical Documentation Primary Insurance or Guarantor None

After the clinical documentation is signed off by the clinician, Insight EMR automatically aggregates procedure codes based upon the documentation of clinical services provided and those charges are processed by your billing department or Clinicient Billing Services. The system automatically takes into account the time spent on clinical services, the length of the visit, standard billing rules and any special billing rules for the primary payer for the patient's case.

Appointment Status

The appointment status may be changed to Arrived in the schedule by the Front Desk, or by the therapist in the clinical documentation. Appointment status is usually changed with a right click shortcut. To change the appointment status to Arrived in the schedule, right click the appointment as illustrated here:

To change the Appointment Status to Arrived from Charting, right click the appointment as illustrated here:

If this is the initial visit for the patient, a panel will appear showing the Case, Topic Selector, and Phrase Categories for documentation. The preview of the clinical documentation will be empty.

If the patient had prior visits for the Case, the procedures done at the last visit will automatically be copied forward to today's date. In addition, any established goals for the patient Case will be copied forward to today's date. Details on Procedure data entry and Goal Tracking are covered in subsequent articles.

Selecting Topics

For Initial Evaluations, select the appropriate topic for the Case:

Selecting Anatomy

Select the relevant anatomy for the Case when appropriate. In the following example, the patient has a problem with the Right Shoulder:

Related Links:

Introduction to Clinical Documentation

Enter Clinical Documentation From Topics

Enter an Initial Evaluation

Enter Daily Progress Notes

Enter Progress Evaluations

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