EMR - Visit Notes

Daily Visit Notes should be entered for each patient visit, including the patien't first visit and if a patient cancels or does not show for a scheduled appointment.

Visit Notes are used to document progression of treatment on a visit to visit basis and also to document charges and treatment that were performed during the visit. If you have one of the billing systems that we interface with, these charges can be exported to the billing system to avoid entering them again in the billing software.

To create a Visit Note 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. Click on the Visit Notes tab. If the patient has already had an evaluation entered, you will be placed on the Visit Notes tab automatically.

 

The second tab will list the Daily Visit Notes in area #1 if any are entered in the database already. Click the "New Visit Note" button (#2) to start a new daily visit note. The screen below will appear. Once the visit note is saved, the date and the subjective information will be shown on this tab. For more information on the features of this screen, see EMR under Documentation.
When adding a new Visit Note, the "Carry Forward" option screen will appear. Select which tabs or areas you would like copied from the last visit note entered to the new visit note being created. This can save a tremendous amount of time when creating new visit notes. In some cases, only a few changes will need to be made on the new visit note.

 

When entering a Visit Note, 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 Visit Note 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 (Subjective, Assessment, Plan)

 

• 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.
• This screen also contains navigation buttons (Previous and Next). These buttons allow the user to scroll through the Visit Notes associated with this case.

 

Note Date	Date of the patient visit
Provider	Therapist or Provider treating the patient
Work Related	Specifies if this case is Work Related or not. If this option is checked, all subsequent notes will also have this box checked.
Cancel / No Show	Specifies if this visit was cancelled or the patient did not show for the appointment. If checked, field #4 (Cancel / No Show) can be filled out to show the reason for the cancellation. When the note is printed and this box is checked, only field #4 will print on the cancellation visit note report.
Fields 1,2,3	Large Search Boxes that can be customized for the wording you prefer. Enter as much text as needed, including carriage returns.

 

Tab 2 - Objective (Tests & Measurements)

 

This tab functions in the same manner as the Objective tab on the Evaluation screen. When entering the first Visit Note, the measurements that were entered on the Evaluation will automatically be entered here as well. 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 3 - Charges and Exercises

• On this tab, charges and exercises corresponding to the charges can be entered. Each charge or exercise will occupy a row in the grid. To get started, click the empty row where "CLICK TO ADD CHARGE" is listed. This will bring up the charges and exercises choice lists as shown below.
• The red text showing above the grid is being pulled from the Restrictions for Insurance Policy 1 that were entered on the Case record screen.

• Charges and exercises are placed into groups on this popup window. To select a charge or exercise, click the appropriate category button and then double-click on the charge or exercise in the list. For longer lists such as the list of Therapeutic Exercises, there is a "Type Ahead Search" box where a user can begin typing in a description and the system will find the closest match.  While the cursor is in the Type Ahead Search text box, the up and down arrow keys will move the highlighted line up and down the list. Once you have what you;re looking for, simply hit the ENTER key to select the highlighted item.
• After all exercises and charges have been selected, click the "Close" button next to the "Type Ahead Search" box to hide the popup window. The screen will then look similar to the one below.

 

• Users can now enter data into the rows starting with the Additional Description column and ending with the Position column.
• If a "Time" value is entered for a charge row (green background), the billing units will be calculated automatically based on the amount of time that represents one(1) billing unit as defined on the Procedure Code record. The calculated units can be overwritten, however, with the "Units to Bill" column. If a case is flagged as Medicare on the case record screen, the 8 minute rule will be applied when calculating units.
• If "Time" is entered on an exercise row, the units will not be calculated.
• Rows can also be moved around on this screen. To move a row, click on the gray box to the left of the row, hold the mouse button down, drag the row to the position desired and release the mouse.
• To select a different charge or exercise that will replace one already listed in the grid, click the row in the "Charge Type" column. The charges and exercises choices popup window will appear again where a different charge or exercise can be selected.
• To Delete a line from the grid, right click on the gray box to the left of the row to delete and select "Delete Line Item"

 

Tab 4 - Other Objective

• This tab contains Search Boxes that are customizable.

 

Tab 5 - 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!