Documentation / EMR

Solid documentation is a central requirement in the operation of a clinic and is a great marketing tool. Returning a well written, well presented progress note or evaluation to a referring physician speaks volumes for the quality of service at your clinic, and is a positive factor in distinguishing your clinic from the competition.

Traditionally, therapists have filled in paper documentation forms. With this in mind, we designed a documentation system that mimics the familiarity of paper forms. This resulted in an easy to use, intuitive interface that any therapist can master with minimal training and minimal clicking.

But this is the only similarity to paper. When one of our forms is attached to a case, it automatically fills-in patient demographic and visit information. Drop down lists are provided in many places so that an entry can be made with a couple of mouse clicks. Textboxes are present to accept entries that don’t lend themselves to selection from a list. Forms also have a digital signature feature that permits the therapist, and only the therapist, to sign the form. Once a form is signed, it is locked from further changes. Forms are also spell-checked.

Unlike paper, all of our forms have the ability to ‘flow forward’ to other forms. Data from the original form is copied forward to the next form and may then be edited. This allows therapists to copy daily notes forward to the current visit and edit their content to reflect that day’s treatment. Evaluations ‘flow forward’ in the same manner except that measurements from the original form are shown in a comparison format on the new form.

Another powerful feature of our forms is the ability to do a ‘Roll up’ which allows you to create a summarized version of the form in a clear, concise letter format suitable for forwarding to referring physicians. Tests and fields that have not been filled in on the form will not be shown on the ‘roll up’, helping to maintain clarity.

Clinic Controller: Therapy ships with a complete set of standard forms and templates. A form designer is also included that lets you modify our standard forms or to create new ones from scratch. Roll up templates may be created in Microsoft Word and offer you all the power of the Word platform to mold the resulting output in any way you see fit. The system permits you to have has many forms as desired, and each form may have an unlimited number of roll up templates associated with it.

All documentation forms and roll ups are attached to a case or a specific visit and stored in the database. Having documentation stored in the system allows front office and billing personnel to quickly and easily retrieve and print the documents.

Finally, forms are stored in a manner that allows Clinic Controller: Therapy to retrieve an individual field from a specific form. This truly makes our forms a data input medium and allows them to be used in outcome studies or as part of other general reports.

Electronic Flow Sheet

In 2011 we introduced our Electronic Flow Sheet.  This tool was built to increase efficiency and compliance.  From the Flow Sheet the therapist documents what they have done with the patient and the Flow Sheet generates the Ojective portion of the daily note and creates the charges so that at the end of the day you end up with a Charge Set, Flow Sheet and Daily Note that are all in agreement with each other.

 

Functional Limitation Reporting / PQRS

FLR and PQRS are all handled within the system.  Therapists are reminded when they are due and ensure that they get them done.

 

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