How do I document a Patient Encounter?

Patient Documentation

To begin the documentation process for a patient visit within in Touch EMR, you must first locate the patient in the system.

To locate a particular patient, you have several options within EMR:

Click on the patient’s name from the Calendar appointment, then click on Patient Dashboard from the pop-up window
Click on Patients from the main menu, and click on Patient Locator
Use the Patient Search Box available at the top right hand corner of the screen (Last Name, First Name)

Patient Dashboard

The Patient Dashboard acts as the patient homepage. Here you can Edit the patient data, view Appointments, Upload documents to the patient’s file, and create an Amendment.

Limited patient demographic information is also listed on the left hand side.

To start documentation for a completed patient appointment:

Click on the Create Patient Record section
Choose which documentation you want to start (Initial Evaluation, Daily Note, Progress Note, etc.)

Flowsheet (Optional) | Mandatory when Medicare 8 Minute or AMA 15 Minute rule is enabled

The user has the option to

1 – Create a new flowsheet component

2 – Edit an existing flowsheet

3 – Delete an existing flowsheet

4 – Preview a previous flowsheet

5 – Duplicate a previous flowsheet

6 – Preview record of all previous components and view entire flowsheet

7 – Create a Flowsheet template

Flowsheet Preview (Specific Flowsheet)

Flowsheet Preview (Overall Sequence)

This is how the flowsheet looks like in a pop-up box.

1. Generate Flowsheet – a separate PDF for the flowsheet to appear on the dashboard
2. PDF Icon – to see how the flowsheet would look like in print

Claim Review

Before you finalize your document you want to make sure and review the Billing tab and all the charges that were entered during the documentation process. You can add, change, or delete the charges from the billing page. In Touch EMR also gives you the opportunity to report PQRS if necessary.

Once your billing charges have been reviewd, click Finalize Document to create your claim for that particular patient visit.

In Touch Biller Pro clients whose account is integrated with In Touch EMR, will be able to review claims sent over from the EMR system within 5 minutes of a Clinician finalizing the document.

Note: If changes were made to the ICD codes in the Subjective section, or charges were edited in the Flowsheet section, you will need to hit the REFRESH button on the Billing tab before finalizing the claim in order for all the new changes to appear correctly.

Compliance Check (Optional)

After you save billing, you will be provided another option called the Compliance Check to check codes that you reported.

Note: The Add Row and CPT Selector buttons will not be enabled once Medicare 8 Minute Rule is turned on.

This gives an overview of codes to be reported for billing and codes reported in the Plan of Care