Objective Section (G Codes)

Objective Section of In Touch EMR

The first thing to note when accessing the Objective section is that there are two tab choices at the top: (1) Builder and (2) Library.

Builder will be the automatic default; this is where you will build a template from scratch.

However, if you already have templates you have created (or have asked your account manager to place done-for-you templates in your account) then you will access them in the Library section to document on.

For more information on templates, contact your In Touch EMR account manager or review the lectures on Template Building 101 in this course.

The template building process is in place to ensure that you have the most customized documentation possible.

Library

From your Library, you will have a list of tempates to choose from. Please Note that you can only associate one template per document.

If you wish to Edit a template (to add or edit a question) while you are in the middle of documenting, you can do so by clicking the edit button after saving your documentation.

Click on the template you wish to document in, and the sections with their related questions will populate below.

You can scroll through the sections of the template, which can be found on the left. Please click “Save” when done.

Editing a template using the template builder

If you decide to edit a template, you will automatically be taken to the Builder section to edit that particular template.

Enhanced objective builder user interface. Fonts are now easier to read and the sample question types viewer can now easily be located. It displays how your question type is going to look like, and facilitates the template building process.

You can edit any question by clicking the “Edit, Duplicate or Delete” buttons.

Once you have finished adding or editing a question, click the green Next button.

A blue confirmation message will appear that your template has been saved.

Then, simply click back on the Library tab to be taken back into your documentation.

Completed templates

Your question will be changed (or added) within the template, and your documentation that you had entered will still remain.

Once done, hit “Save“.

You can then proceed with your documentation using your custom template.

Note: The system will NOT allow you to delete a template that has already been used for patient documentation.

Once a template has been used to document a patient encounter, it cannot be deleted from your library.

If you choose to update a template or revise a template we suggest you make a Duplicate first, then make and save your changes/edits, and rename the template with the date of the revision.

For example, “ABC Template-Revised on DD/MM/YY”.

For more questions on the Objective section or template building, contact your In Touch EMR account manager or our support team at support@intouchemr.com

 

The ‘clear’ button on the Objective section

When an Initial Evaluation is created, it becomes the foundation for future notes. Data from the initial evaluation gets carried forward to the next note (including the data from the objective section). As the patient treatment progresses, some of the data carried forward, in certain sections of the objective section, is no longer needed.

In the past, users had to manually delete this data, one field at a time. Not anymore! In Touch EMR now introduces the ‘clear button’. This button appears in each objective section of every objective template in any note type.

To clear data from a specific section, simply click ‘clear’ to delete the data on that section. This will remove all the data from that section only, and other sections will remain unchanged.

In the diagram below, the highlighted section is an indication that the data on it have been carried forward from the previous note.

In this example, the highlighted ones are ‘Functional Limitation’, ‘Muscle Length’, and Range of Motion.

This means, that the data on the highlighted sections will get cleared/deleted if you click on the ‘trash’ icon.

Here’s how a ‘trash’ icon look like. Click it to clear sections you wish to remove data from.