EMR - Evaluation

To create an Evaluation 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.

 

After creating the Evaluation, there will automatically be a first Visit Note created.

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

 

• When entering an Evaluation, the only required fields are marked with an asterisk (*). These include the date of the note, the provider name, and the primary diagnosis. All other fields are optional.
• The Evaluation 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 many 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 of the evaluation
Provider	Therapist or Provider who performed the evaluation
Diagnois 1	Primary diagnosis for this case
Diagnosis 2,3,4	List additional diagnoses if needed
Provider Diagnosis	The diagnosis the therapist has given for this evaluation if it does not match the primary diagnosis given by the referring physician
Physician History	List of physicians the patient has seen in the past
Onset Date	Date of Injury or Onset
Surgery Date	Date of surgery, if any
Hosp From/Through	Dates patient spent in the hospital for this diagnosis
Next MD Date	Date of next doctor visit
Next Progress Note Date	Date when the next Progress Note is due for this case. When adding a new evaluation, this date defaults to 30 days past the Note Date, but can be changed if needed.
Work Status	Patient's work status.
Job Class	Patient's Job Classification
Employer	Patient's Employer
Dominant Hand	Patient's dominant hand or side
Affected Area	Side that is affected
	There is also an information area in the lower right side of the screen to display fields such as the patient's name, the date the evaluation was created, who created it, etc.

 

Tab 2 - Subjective

 

This tab contains mainly Search Boxes that are customizable.

There is also an area on this tab for a Pain Scale and check boxes to indicate whether the patient experiences dizziness or numbness.

 

Tab 3 - Objective

 

Again, more search boxes that can be changed for each patient type to fit the needs of your practice.

 

Tab 4 - Assessment / Plan

 

Contains two more search boxes used for the Assessment and the Plan for the evaluation. If these field labels (23 and 24) are modified under Patient Types, they should reflect a description similar to assessment and plan.

 

Tab 5 - Tests / Measurements

 

This tab is the place to enter the results of the tests and measurements performed on the patient. There is also a field on this screen called "Other" at the bottom. This is a free text field where you can enter as much text as needed.

• For more information on how to use this tab, see Tests / Measurements under Common Program Features.
• For information on customizing this screen, see Tests / Measurement Setup under Documentation.

 

Tab 6 - Custom

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!