Documentation from Start to Finish

Step One: Creating a new Note (Initial Evaluation, Progress Note, etc.)

Navigate to the patient dashboard and you will be given the option to create different types of documents.

The first step to creating a new patient note and beginning the documentation process is to access the patient you wish to document for.

Once you are in the Patient Dashboard, you will want to select “Create Patient Record” and choose from the drop-down list of notes.

Initial Evaluation will only be a selectable option for the first patient visit.

Patient Dashboard

Alerts & Notes may also be edited from the patient dashboard – shown in figure A and B.

To edit, please click on the pencil icon. Once clicked, this will redirect you to the appropriate pages.

Document in Progress

Once you have started a document and it is in progress (in other words, it is not yet finalized), it will appear in the Documents in Progress section where it can be resumed.

User can do the following while the document is in progress:

1. Preview a document in progress (as long as relevant components have been saved) while working on a SOAP note. Click on the PDF icon to preview the information based on the relevant components saved on the SOAP note. 
2. Edit or resume working on the note by clicking on the pencil icon adjacent to the document in progress.
3. See the date of service of the document in progress.
4. Resume working on the note using the global vertical scroll.
5. Delete a document in progress.
6. View the billing/claim information by clicking on the ($) dollar icon.

Note: the billing/claim information will only be available if the user already clicked on ‘SAVE BILLING’ under the Claim Review tab.

After you finalize the document, sign it electronically and it is sent to the billing software for processing, the document will appear in the Completed Documents section and will no longer be editable in In Touch EMR.

Note : The Total Visits will update according to the number of documents you create under the patient details. it will also show the episode’s title that the user is working on.

Step Two: Adding a Title to your Document

1. Users are given an option to title any document created. To add a title, enter the information on the ‘Document Title’ field. Once done, click on ‘SAVE TITLE’

2. Once the title is added, it will appear right next to the note type in the Patient Dashboard.

Note: The Document title can be added inside the document while it is in progress.

Related Appointment

The first tab of the documentation process is the Subjective tab.

In our comprehensive Subjective tab, you first need to enter the Related Appointment.

This is very important as it tells the system (as well as potential auditors) that you are documenting for a patient visit, and not documenting without having a patient scheduled in the first place.

Episode’s Title

Episode title now shows right next to the document in progress bar(note type- Episode title) This will help the provider identify for which episodes the note is being created for.

Note that the Episode title will only be available for the following note type; Daily, Progress, re-evaluation and Discharge Note.

1. Progress Bar
2. Document/Note Type
3. Episode Title
4. Date of Service

ICD Codes

The subjective tab is also where your Treatment Diagnosis codes (ICD codes) will be populated from.

You can simply click the “Add” button and a handy menu will come up, allowing you to search by description or code.

Once you have added these ICD codes, they will appear on your billing tab for review before the document is finalized.

Make sure to hit “Save” at the bottom when finished.

ICD Code database

You may enter the the specific ICD code that you are need or you may enter a description to locate the corresponding ICD code

Note : For frequently used ICD codes, it is more convenient to add it to the Most Used Tab for easy access.

To add an ICD code on your ‘Most Used’ list, click on the ‘star’ icon adjacent to the ICD code that you wish to add.

Truncated ICD 10 Codes in In Touch EMR

Flagging of unspecified / invalid / truncated ICD-10 codes – In Touch EMR now displays a ‘flag icon’ next to the code and the ‘Add’ button in red for over 4000 unspecified / truncated / invalid ICD-10 codes, alerting the clinician that these codes can lead to clearing house and / or payer rejections. If you want to review the entire list, please click here to access the entire list of ICD-10 codes to avoid.

This was achieved with the effort of all the ICD-10 certified coders at In Touch Billing, the sister company of In Touch EMR, who identified a list of over 4000 truncated / invalid / unspecified ICD-10 codes for In Touch EMR users.

Step Three: The Objective Section (Template-Based, Functional Limitation G Codes)

Objective

The Objective section is completely template based and fully customizable to your needs.

From your Library section, which is comprised of templates that you create as well as templates that your account manager has put into your account for you, you can choose the template you wish to document in.

Choose the template you want to user on the Objective section using ‘Choose from Templates’ box. Just highlight the selected template and this will automatically get loaded.

Step Four: The Flowsheet Section (CPT Codes)

Flowsheet

Flowsheets are very helpful high-level tools for seeing your exercise regimen for a particular patient as it changes or stays the same over time.

The first step to creating a flowsheet is to hit the green “Add New” button.

PLEASE NOTE: ONLY CREATE ONE FLOWSHEET PER PATIENT NOTE/VISIT.

The codes for your billing section will populate from the Flowsheet you create (or copy) during this visit, so it is important that you only maintain one.

1. To start a brand new flowsheet, click on ‘Add New’

2. You can title your flowsheet on the ‘FLOWSHEET TITLE’ field.

3. Tick on ‘SAVE as TEMPLATE’ tick box to save it as an additional template on your template library.

4. The date is always defaulted to the current day but is editable. Click on the calendar icon to change the date.

5. From there, you can enter in the exercise description, reps and sets, durations, treatment precautions and notes for each individual component (or exercise).

6. In the Charge As field, you can choose from a menu of CPT codes by clicking the green “CPT Selector” button. The codes you enter here (or copy from a previous flowsheet) are what will populate into the billing section.

7. Once you have filled out the form, to add the exercise, click Add Component.

8. When you are done, hit Save Flowsheet.

Note: Do NOT create a new flowsheet for each exercise.

CPT Code selector

Flowsheet Options

The user has the option to

1 – Create a new flowsheet component

2 – Duplicate a previous flowsheet

3 – Edit an existing flowsheet

4 – Preview a specific flowsheet

5 – Delete a flowsheet

6 – Preview all the flowsheets created

7 – Template Builder

Once you are done with your flowsheet, you will see it in the flowsheet list.

You will see the (1) title and (2) date of associated appointment, as well as a (3) lock icon indicating the flowsheet is not active.

Current flowsheet charges are what will appear in the billing tab for the clinician to review, before the document is finalized.

(4) You can click the blue “Preview” button to see an overview of all exercises for that patient from your previous and current flowsheets.

(5) The flowsheet list when collapsed only shows 3 previous flowsheet on the list and 10 when expanded.

Flowsheet Preview

This shows the overview of all exercises for that patient from your previous and current flowsheets.

Flowsheet Pop-Up

This is how the flowsheet looks like in a pop-up box. All charges/CPT Codes that were confirmed to be billed will be in black font and all in red are part of the flowsheet template that were not propagated.

Step Five: Assessment

The Assessment section is very straightforward.

This is where you will enter in your Clinician Assessment narratives as well as the patient and caregiver education.

Click “Save Assessment” when done.

Step Six: Plan Section

In the Plan section, you have an in-depth look at your overall goals and services provided.

You will be able to see your Treatment codes, as well as any goals you have entered throughout the documentation.

You can also enter in new goal by clicking on (1) ‘Add Goal’. From here, you can add in additional comments as well as sign the document.

You can Save as Draft, Generate Plan of Care (meaning the document will appear in the Patient’s Dashboard) and also View as a PDF.

Note: You will only want to Generate a POC when necessary (usually during an IE, Reeval, or Prog Note), otherwise the Patient Dashboard will show a PDF for every POC. For Daily Notes or other times when a POC is not needed, use the “Save as Draft” option to save your information.

Dynamic Goal Box Improvements

Ability to add / designate the goal start date and goal end date. Ability to designate a goal as ‘100% met’.

Functional Limitation G Codes now appearing on the plan of care

Goal set for the patient now appears on the Plan Section under Goals.

Saving/Generating a Plan of Care

There are several options under this section

You may enable or disable information shown on the PDF file generated for a saved Plan of Care

1. PHYSICIAN OPTIONS

is the Physician Signature Required – If this is disabled, the physician signature fields will not show on the plan of care. Generally, this should enabled since the signature fields are required on the plan of care.

Physician Name Display – when enabled, the name of the physician appears below the signature field. This is an optional feature and the clinician can decide if the physician name display is required on the signature fields.

2. PROVIDER OPTIONS

Extended Provider Signature

When a patient is being seen be more than one clinician, this option allows the designation of this additional / extended provider and this additional providers signature will also appear on the plan of care in addition to that of the rendering provider

Rendering Provider Signature

Only licensed healthcare professionals (PT, OT, Speech and Mental Health Professionals) appear in this list. The signature of the selected rendering provider will appear on the plan of care.

Step Seven: Billing Section

Billing

In the Billing section, you will see all the ICD codes from the Treatment Diagnosis field of the Subjective section, as well as the CPT codes from the Flowsheet section.

If you do NOT see these codes automatically appear, please hit the (1) Refresh button.

(2) PLEASE MAKE SURE that you ALWAYS assign a minimum of one Supporting Diagnosis to your CPT Code rows.

The system will not finalize the billing unless there is a supporting diagnosis attached, as a safety measure to ensure depth of claim.

Essentially, you are telling the insurance company that you are charging your CPT codes for the related ICD codes. This is also where the G Codes will populate. Please note that the system automatically assigns a Unit of at least 1 to each code row. For more information on transmission of ICD and CPT codes from In Touch EMR to In Touch Biller Pro, please click here.

When you are done, click (3) Save Billing.

Note:

If you wish to add a row of CPT codes, hit the ”Add Row” button. You can also enter modifiers from a menu of modifiers.

Improvements to auto-populate diagnosis pointer on Claim

In Touch EMR is now able to populate the first (or all) of the diagnosis pointers automatically on the claim form to help save time for the clinicians.

When you hit the Refersh Button, the supporting diagnosis code will auto-populate in the boxes.

Note: The supporting diagnosis code will auto-populate in the boxes ONLY if the Autopopulate Diagnosis Pointer on Claim has been set to YES. This option is available under Administration > Staff > Edit

Finalizing your claim

Once ‘SAVE BILLING’ is clicked, you will see a blue message that says (1) ‘Well done! Your claim has been saved and is ready for submission when you click ‘Finalize Document’

(2) Click ‘FINALIZED DOCUMENT’ to complete the process.

One Click Save

This can be found in the upper right side of the Documentation Section.

  1. S – when clicked saves the Subjective Section.
  2. O – when clicked saves Objective Section.
  3. F – when clicked saves the Flowsheet Section.
  4. A – when clicked saves the Assessment Section.
  5. P – when clicked saves the Plan Section.
  6. C – when clicked saves Claim Section.
  7. D – when clicked saves the where ever section you are at while documenting and will lead you to the Patient Dashboard page.

Global Vertical Scroll

By default, this is set to ‘NO’ for all providers. When enabled, this provider will see a ‘globe icon’ adjacent to the document title on the patient dashboard. When the user clicks on the globe, you’ll see S, O, F, A, P components in one tab (Global) one below the other and Claim Review in a separate tab. The user see all elements carried forward from the previous note and will be able to scroll down past the Subjective, then Objective, then Flowsheet, then Assessment, then Plan sections. The user will NOT have the ability to answer questions that were NOT entered in the previous note (this option, along with the ability to choose templates is available in the traditional documentation panel).

Advantages of this feature:

1. Ability to view all data without having to click on tabs
2. It will ONLY display questions and answers that are carried forward, and allow editing of these fields.
3. Auto-save will save all data in all sections.
4. All traditional features like auto text, goal box and flowsheet popups will work exactly as expected.

Limitations of this feature:

1. More time spent scrolling up and down. For example, the user will scroll down past subjective before you can get to objective. Scrolling can be reduced by using the top section buttons (at the top of the page) to auto-direct to either S, O, F, A, P. Scrolling (to go up from the bottom) can also be reduced by using the blue circle button (on the bottom right side of the page) to auto-redirect to the top section.
2. If you want to select additional questions or change templates, the traditional view must be used.
Enhanced search capabilities including the ability to run a search by mixing and matching appointment types and appointment status. This is available on the traditional calendar and the multi-resource view as well.

Sample view of Global Vertical Scroll

Clear Data Function in SOAP note

In Touch EMR carry forward automation has been a big help in terms of doing patient notes. Carry forward automatically carries the information forward to the succeeding note which is very efficient to the users. However, there are times that users does not need the information to get carried forward to the succeeding note. That’s why In Touch EMR added a ‘clear data’ function in SOAP note. This function allows the user to have the option to delete the entire data on the new note from the information that got carried over from the previous note.

To do this, click on the ‘Red X’ inside a SOAP note adjacent to the carry forward button.

Once clicked, the system will give a pop up alert saying ‘Are you sure you want to delete all of the data from this document? This will delete existing data of this note.”. Two options will be given; to continue, please press (1) ‘DELETE’ button, to discontinue, press (2) ‘CANCEL.

Delete Function for Initial Evaluation

Initial Evaluation can now be deleted if the only note in progress is the Initial Evaluation, and there are no other finalized documents.