HealthCORE

Daily Visit Documentation - HSWorx

Updated on

This training explains how to document the daily visit in the most effective and efficient way, starting with the patient's input via the kiosk and ending with charge entry. Documenting a daily visit takes 60-90 seconds.

Patient Input from the Kiosk

Patients enter key information for the visit during check in at the kiosk:

Daily Questions

  • VAS - Pain Level
  • Pain Frequency
  • Primary Pain Quality

Weekly

Daily questions plus:

  • VAS - Pain Level
  • Pain Frequency
  • Primary Pain Quality
  • 3 outcome assessment questions

This information lays the foundation for the visit. Make changes or notes as necessary.

Answer all the question with red indicator and that section will collapse to answer other complaints questions

Documenting the Visit

In addition to current information from the patient, key information flowing from the exam, the treatment plan, and the last visit are added according to your determination in setup. Select the patient from the Stack to begin.

Click on Doctor Icon to view the Doctor Stack

  1. Select Doctor - Doctor that is treating should be listed here
  2. Schedule - Doctor that is showing in field 1 will show that Doctor Schedule for the Date on the Top
  3. Show All - shows all patients in the date range set
  4. Show Complete - shows the completed notes on the Date you are looking at
  5. Date - date of the notes you are working on
  6. Filter By Provider - If you have more then one Doctor check Filter By Provider and will only show notes that are schedule for that provider
  7. Overdue Visits - All Charges and notes that have not been completed
  8. Doctor Stack - Shows all patient appointments Signed In

The top part of the window includes at-a-glance information about visit dates and visit frequency. To look at data from a prior visit, click the Last Visit at the top of the window and select from the pull down list. Also shown are the statuses of the Super Bill and Report. When they are complete, a Green indicator will appear next to each.

Work through each section of the Visit Summary to review existing information and update according to findings and treatment during the visit.

Reason for Encounter

The Reason for Encounter is entered automatically, based on the Visit Type for that day. Use the pull down selector to make a change.

  1. Providing Treatment - If checked the Chiropractic Techniques, Modalities, and Exercises buttons will show
  2. New Complaint - If checked you are entering a New Complaint or patient answered Yes to New Complaint, Injury, Accident or Fall since last visit

Current Complaints

There are multiple options for viewing information about Current Complaints. The main information is summarized, including naming each complaint and reporting the current VAS. Click the Current Complaints tab to see more summary data or click the hyperlink on the complaint to see details.

  1. Location - Current Complaint
  2. Region (SHI) - Region for the Spinal Health Index Report
  3. Date of Onset - Date of Onset for Box 14
  4. Outcome Assessment - Spinal Health Index will show which test and score
  5. Additional Information - Text field to write Additional Information
  6. VAS Current - Pain Level for Current, Worst, Average, or Best
  7. Compared to Last Visit - Are they Same, Better, or Worse
  8. Percentage Improvement Since First Visit - Percentage of Improvement since First Visit
  9. Frequency of Pain - Frequency they experience Pain throughout the day
  10. Show Subjective - Click to see Subjective info of complaint
  11. Delete Complaint - Delete Complaint
  12. Change to Primary Complaint - Click to change a complaint to Primary Complaint
  13. Resolve Complaint - Click to Resolve the Complaint

Story

To add information in the Story section, begin typing in the text box or click the Story tab to open a window that allows for more detail. In the detail window, add and save default Micro-Notes that you use frequently. This saves time typing and allows you to make modifications as needed.

Palpation/Observation

Click indicators to show what has changed on the visit.

  1. Link Adjustment - Check box to add in the Technique Automatically when selecting the Fixation
  2. Link Spinal Palpation - Check box to add in Pain/Tend and Spasm Automatically when selecting the Fixation
  3. Severity Selector - Click the Severity you want to start with when clicking in the Fixation fields
  4. Show Labels - Check if you want it to show S for Severe, MOD for Moderate, MILD for Mild, and WNL for Within Normal Limit
  5. Clear All - Clears the whole grid
  6. Import From Previous Test - Click to select the last Palpations/Observations you want to Import
  7. Technique Settings - Click to setup the Adjustment that will Automatically fill in the Technique boxes

ROM and Posture/HSMS/Ortho/Neuro

There may be occasions in the course of a daily visit where information in these areas is adjusted, but mostly these are exam related.

Specific Exams

Click the Specific Exams tab to see a summary of all available exams or click the link in the summary window to update findings for that patient's complaint.

Diagnosis

Click on Diagnosis to Update or Change Diagnosis Codes

The Diagnosis window displays favorite options on the left and current diagnoses on the right.

  1. Search for a specific code by keyword or code
  2. The default list on the left is Favorites. Use the pull-down selector to choose the Wizard, which helps you find the code by body region.
  3. Current diagnoses appear in the right-hand panel.
  4. Refresh arrows to refresh
  5. Clear Diagnosis to Clear
  6. Finished when you are finished selecting all diagnosis needed
  7. Show history click icon to the history or last set of diagnosis codes

Assessment

The Assessment shows how a patient is progressing to their specific, objective goals. Type a brief statement or click on an existing Micro-Note, which allows you to enter specific information on how the patient is progressing without having to type long descriptions.

Chiropractic Techniques, Modalities and Exercises

Treatment Plan Chiropractic Techniques, Modalities, and Exercises - https://help.healthcoretech.com/a/1262024-treatment-plan-chiropractic-techniques-modalities-exercises

Click any of the tabs to document what occurred during the visit. Modalities and Exercises show as Planned until they are performed by the doctor or the therapist. If the patient has been to therapy prior to their adjustment, it will say Performed.

Plan

The Plan section will Automatically fill in with "Patient will return for follow-up on" next appointment date.

The Plan section can be as simple as noting the next visit or, by click the tab, you can choose another option that better reflects the plan for the patient.

Visit Calendar

The calendar on the bottom right portion of the window displays a wealth of information about where the patient is on their treatment plan and the status of their visits.

The left-hand column displays the week of the treatment plan. The right-hand column shows the number of visits scheduled and the number of those for which the patient was present. In the calendar grid, the colors reflect patient attendance.

  • Red = Did not come for visit
  • Green = Signed In visit
  • Yellow = Rescheduled visit
  • Black = Scheduled future visit

Super Bill

Charges reflecting what was performed during the visit are automatically added to the Super Bill. Add or delete if needed.

If the patient has not been for therapy at this point, the anticipated units will appear. If the patient does not perform therapy as expected, the therapist will be prompted that there is a mismatch between the Therapy Log and the Super Bill and asked to make the modification to the correct value when they're signing off on therapy.

When you are finished diagnosis pointing, make sure Treating Provider is correct. Then you can choose Sign & Complete or View Report and then you will Sign at the top.

If the Therapy Log is not initialed when the doctor is signing the note, this window appears. At this point there are two options: 1) manually enter the In/Out times and initial to click Continue or 2) click Send to Therapy where the therapist will document the session and sign off on that portion of the visit.

Charge Entry

There is a separate Charge Entry training that delves into the details, but having a basic understanding of what's next completes the process.

Pending Charges are listed on the left. Team Members will work through each claim to verify charges, add modifiers if needed, and collect or apply payments from patients.

This window includes the same calendar view as shown in the Daily Visit Summary. It's a quick way to see if patients have future appointments scheduled. Clicking on a specific date allows you to add an appointment from this calendar, either in Charge Entry or the Daily Visit.