Transition Clinical Documentation from Legacy Systems
How to transition important information from your existing clinical documentation system to Clinicient.
Note: This should only be done during your initial implementation as you transfer from your legacy system to Insight EMR.
Clinical documentation on existing patients is not transferred to Insight EMR automatically, so some baseline information on existing patients must be entered into Insight EMR:
- Prior to entering documentation on existing patients, their basic demographic and case information must be entered into the system.
- You may enter baseline documentation information for these patients on the first visit after your clinic goes live, but it is possible to enter baseline documentation information on these patients before going live. The process for both of these options is described below.
Entering Baseline Case Information
The Case Information should include the Admit Date, which is the date that the patient was first evaluated for this case.
Note: It is not necessary to include the Admit Date for patients if their initial visit for a case is documented in Insight EMR.
Entering First Visit Documentation
Start patient documentation by clicking Start . A prompt displays to confirm you would like to start documentation on an un-arrived appointment. Click Yes to continue.
After launching documentation for the first visit for the patient, use the Chart Transition Template.
Before adding pertinent clinical findings, switch to an appropriate Topic.
Prior to adding important clinical test results, you may need to declare the affected anatomy. Click the skull icon and then select the affected anatomy as illustrated here.
Add results of important clinical findings you will need to track going forward from the topic tree.
Adding a Series of Clinical Tests Enter the results of the important clinical findings along with the contralateral results as appropriate.
Earmark important clinical findings that you will need to track for goal progression.
Important clinical findings that you would like to include as goals going forward can be included in the documentation for the first visit in Insight EMR for your continuing patient.
When documenting goals for a patient, the Initial column automatically duplicates any goals that were entered in the Current column. Text in the Initial column is gray and ready to be edited, as needed to indicate the original findings from your legacy system. Just highlight the text in the Initial column and enter previous clinical findings to overwrite what was entered. When you make changes to the Initial column, the text color changes to black. The Initial column is only editable on the patient's first visit for the selected goal.
Enter Functional Limitation Reporting at Sign Off
To eliminate unnecessary denials from Medicare, select the same Impairment Category that was used in the legacy system.