EMR Chart - Care Plan

To create a Care Plan for a case, access the patient list, select a case, and click on the "Open EMR Chart" button to access the chart. The screen below will appear.

The first tab will list the Care Plan in area #1 if one is entered in the database already. Click the "Add Care Plan " button (#2) to start the care plan. The screen below will appear. Once the Care Plan is saved, the date and the Treatment Plan will be shown on this tab. For more information on the features of this screen, see EMR Chart under Documentation.

 

When entering a Care Plan, the only required fields are marked with an asterisk (*). These include the date of the note and the provider name. All other fields are optional.

The Care Plan is made up of several Tabs and there is a lot of information that could be entered for this medical record. There are also several features that can make data entry quicker.

• This screen contains drop-down lists that are common to the system. To learn how these operate, see Drop Down Lists under Common Program Features.
• These tabs also contain many Search Boxes that are customizable. The screenshots below  show what the field labels will be by default. These labels can be changed for each different patient type that is added to the system on the Patient Types screen.  For more information on how the Search Boxes function, see the section under Common Program Features.

 

Tab 1 - General

The "Complete" check box is common to all notes. Marking a note as complete will add that particular note to a "Batch" of notes. If the option to "Lock Completed Notes" is checked (see Options), only users marked as Administrators will be able to make changes to a note once it is marked as Complete.

 

Note Date	Date the Care Plan was issued. Usually will match the Evaluation Date unless this is an additional Care Plan being added to the chart.
Provider	Name of therapist or Provider entering the Care Plan.
Planned Frequency of Visits	The number of visits each week that the patient will be seen. If, for example, the patient's first visit is on a Friday, Week 1 should have the number "1" selected to show that the patient was only seen once the first week.
Prescribed Frequency	The number of times per week and the duration the patient was prescribed therapy.
Treatment Plan	Customizable Search Box.
Print Physician Signature	On some Care Plans, it may not be desireable to show a Physician Signature Line. This option determines whether or not the signature line will print on the note when the "Print" button is selected.
Print Physician Agreement	If the Print Physician Signature is selected, this option can also be selected. It determines whether or not an area prints on the Care Plan where a physician can check a box to Agree or Not Agree with the treatment outlined and also provides lines for the physician to fill in comments if needed.

 

Tab 2 & 3 - Problems and Goals

These problems and goals tabs are similar in the way that data is entered. The Goals grid will vary slightly from the Problems Grid.

There are several ways to enter data into the problems and goals grids.

• Method 1 - Free Typing.

  

 

Click on the row that reads "CLICK TO ADD RECORD". Begin typing in the text box that appears. To move to the next field, press the TAB key. To move backwards through the grid, press the SHIFT+TAB key.

•  Method 1 - Call up the Search Window.

With the search window open, search for or double-click on an item in the list. You will see the items selected get added to the grid in the background. When finished, close the search window. For more information on how this search window works, see the section Search Window under Common Program Features.

• Method 3 - Load a Template!

Templates can be created for each Diagnosis in the database. These templates can contain any number of Problems, Short Term and Long Term Goals. Once a template is created, simply click the "Load Template" button on this screen and make any changes necessary to the list that loads automatically. For information on creating these templates, see the Diagnois section under the Lists Menu.

 

• Method 4 - Use the Copy button.

Once the problems are entered on the Problems Tab, select the "Copy Problems" button to copy the list of problems to the Short Term Goals list. From there, the list can be edited to represent the short term goals for each problem After the Short Term Goals are entered, click the "Copy Short Term Goals" button to copy the list of short term goals to the Long Term Goals list. From there, the list can be edited to represent the long term goals for each short term goal.

 

Tab 4 - Custom Fields

The final tab is reserved for any additional fields that you may want to add to the Evaluation. To add additional fields, change the "NOT USED" fields on the Patient Types screen to whatever you would like them to be. Once you create a custom field, it becomes a Search Box so that you can also create a list of choices for it!