The Plan Section

Plan of Care

The first thing you will notice is, you will be prompted to answer the question “Is the treatment plan related to the functional outcome expected?” The answer will be based on the clinician’s assessment. The user have the option to select ‘YES’ if he/she think it is related and ‘NO’ if it is not.

ICD Codes autofill

You will then see the ICD codes you selected from the Subjective section, as well as a Description.

Underneath these ICD codes you will be able to select the frequency and duration of your plan.

Goals

1. Under the “Goals” subheader, you will see all of the patient goals that you have entered throughout your documentation in the dynamic green “G” boxes.

2. You will also have the option to enter new goals by clicking the ‘ADD GOAL’ button.

3. You can also edit and delete any goals from the plan.

 

Note: If you choose to enter your goals while documenting in the Subjective or Objective sections by using the green “G” boxes within the template questions, then your goals will automatically appear on the plan section. You will have the same options to Edi or Delete those goals just as you would if they had been created in this section.

Types of Service

By clicking the Select Type of Service button, you can choose from a wide variety of Procedures and Modalities to make up your plan.

You can add more procedure and modalities in your current list by clicking on the edit (pencil icon). You will be directed to Administration > Types of Services (Plan)

You can then view an overview of your plan of care by selecting the Services once they are added.

You also have a space to enter in a description.

To delete a service type, right click on the service you wish to remove, and choose “delete”.

Instruction/Intervention

Click on Add New an Instruction for the Plan

This pop up will appear. Please choose the (1) Instruction/Education from the dropdown, (2) fill out the start and end date and (3) put comments if needed. Click on (4)Add to complete the process.

Generating a Plan of Care

You can sign the Plan of Care electronically before saving it as a Draft (saving it in your documentation only), Generating a Plan of Care (saving the Plan on the Patient Dashboard as a separate document) or Viewing as a PDF by clicking the PDF icon.

If you choose YES for the Physician Signature required, more options will be provide (Physician customization, Plan Approval and Review) 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.

1. Physician Customization (optional)
If this is enabled, the physician the option to customize / change the plan of care. Generally, this is disabled by most providers.

2. Plan Approval and Review (optional)
When enabled, the following text will appear on the plan of care, prior to the signature fields. “I certify that I have examined this patient and treatment is medically necessary. The services will be provided while the patient is under my care. The plan established will be renewed every ninety days or more often, if the patient’s condition requires it.”. Generally, this should be enabled.

3. Physician Name Display (optional)
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.

 

4. Extended Provider Signature (optional)
When a patient is being seen be more than one clinician, this option allows the designation of this additional / extended provider and this additional provider’s signature will also appear on the plan of care in addition to that of the rendering provider

5. Rendering Provider Signature (strongly recommended)
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.

6. Save as Draft (optional)
When clicked, all the changes in the plan of care are saved, and become part of the clinical record and carry forward into future notes. It is important to save your changes in the plan of care using this feature.

7. Generate Plan of Care (optional)
When clicked, the plan of care is generated as a stand-alone document on the patient dashboard.This generated plan of care can be printed or faxed electronically to referring physicians. This is ideal for referring physicians, who may want to see the plan of care only, instead of the entire clinical record

POC PDF

When you click the PDF button, you can view a preview of your Plan of Care.

As you can see, there are Objective components entered that directly relate to the Plan of Care.

You also have an in-depth look at your plan and goals.

Plan of care improvement

Plan of care improvement – Relocation of ‘type of service’ on plan of care. This field has been moved up on the plan of care, so that it appears below frequency, duration and certification period, but it appears above goals. This change will also reflect on the PDF of the plan of care.

PDF of the Plan of Care

Dynamic Goal Box

(*) indicates required fields.

Alerts on Dynamic Goal Box

Alerts are set up on dynamic goal boxes to guide users about required fields that are missing / incomplete.

Edit icon in the plan of care

An edit icon is available adjacent to the procedures and modalities in the plan of care. This allows one click redirection to the procedures and modalities section, allowing the user to edit them as needed.The plan of care listings on the patient dashboard also show the ‘source documents’ i.e the documents from which the plan of care was generated (initial evaluation, progress note, reevaluation of daily note). This information is also reflected in the PDF of the plan of care.

1. Click on the ‘Edit’ icon adjacent to the Procedure to add more procedure on your current list.
2. Click on the ‘Edit’ icon adjacent to the Modalities to add more modalities on your current list.

Multiple delete option under procedures and modalities in the Plan of Care

In the past, In Touch EMR allowed users to delete one procedure or one modality at a time. Now, In Touch EMR will allow you to delete multiple items at the same time. To do so, choose multiple items by pressing the CTRL key on your keyboard and left click to select the items. Once selected, right click and click delete. All the selected fields will now delete.

1. Most used list for procedures / modalities now available in the plan of care– Similar to the most used list under ICD-10 codes, you can now identify your most commonly used procedures and modalities and add them to the ‘most used’ list for quick reference.

2. The plan of care pop up now shows upto 50 procedures / modalities at one time, instead of 10

3. Click on the ‘Star’ icon to add the procedure/modalities on your ‘Most Used List’.

Mandatory Components for Plan of Care

To enable this feature got to Admin > Staff.

By default, this is set to ‘No’. This means that the following components in the plan of care are NOT mandatory for users:

1. Frequency and Duration 
2. Certification Period 
3. Procedures 
4. Goals

When set to ‘Yes’, In Touch EMR will require ALL of the following components to be on the plan of care, before allowing the user to finalize the document.

1. Frequency and Duration 
2. Certification Period 
3. Procedures (a minimum of one procedure or modality)
4. Goals (a minimum of one goal) 
When set to ‘Yes’, the user must get into the habit of clicking ‘Save Draft’ to save data in the plan of care. Then, the user must proceed to ‘Finalize Document’.

If the user clicks on ‘Save Draft’, and any components are missing, then the user will see the appropriate error message on the plan of care page (Frequency and Duration missing, Certification Period missing, Minimum of one procedure missing, Minimum of one goal missing). The user must enter the missing data and then ‘save draft’ again. Now, when the user proceeds to finalize the claim, he / she will be able to.

If the user ignores the error messages, and proceed to finalize the claim, he / she will be unable to finalize the claim. An error message will appear when the ‘Save billing’ button is clicked (Please enter missing components in the plan of care).

If the user ignores the plan section entirely / forgets to click the “save draft’ button, then he / she will be unable to finalize the claim. An error message will appear when the ‘Save billing’ button is clicked (Please enter missing components in the plan of care).
By default, this is set to ‘NO’. This means that the flowsheet preview (flowsheet summary of everything done for a particular date of service) is a separate, stand-alone document that can be printed and faxed separately.

When set to ‘YES’, the user will be asked to select a designated document type (initial evaluation, progress note, daily note, re-evaluation and / or discharge). One or more documents can be selected. Once selected, the flowsheet preview (associated with the same date of service) will also appear on the PDF of the selected document type(s). This applies to that particular user.

Let’s assume this setting is enabled for the daily note for the user ‘sam234’. When ‘sam234’ uses In Touch EMR, the enabling of this feature allows the user to generate and fax ‘combination PDFs’ that include the daily note and the flowsheet preview (associated with the same date of service) to the referring physician or payer. This allows the user to print and / or fax clinical documentation in addition to flowsheets (what was done) at the same time.
– to enable this feature got to Admin > Staff.
By default, this is set to ‘No’. This means that the following components in the plan of care are NOT mandatory for users.
1. Frequency and Duration 
2. Certification Period 
3. Procedures 
4. Goals 
When set to ‘Yes’, In Touch EMR will require ALL of the following components to be on the plan of care, before allowing the user to finalize the document.
1. Frequency and Duration 
2. Certification Period 
3. Procedures (a minimum of one procedure or modality)
4. Goals (a minimum of one goal) 
When set to ‘Yes’, the user must get into the habit of clicking ‘Save Draft’ to save data in the plan of care. Then, the user must proceed to ‘Finalize Document’.

If the user clicks on ‘Save Draft’, and any components are missing, then the user will see the appropriate error message on the plan of care page (Frequency and Duration missing, Certification Period missing, Minimum of one procedure missing, Minimum of one goal missing). The user must enter the missing data and then ‘save draft’ again. Now, when the user proceeds to finalize the claim, he / she will be able to.

If the user ignores the error messages, and proceed to finalize the claim, he / she will be unable to finalize the claim. An error message will appear when the ‘Save billing’ button is clicked (Please enter missing components in the plan of care).

If the user ignores the plan section entirely / forgets to click the “save draft’ button, then he / she will be unable to finalize the claim. An error message will appear when the ‘Save billing’ button is clicked (Please enter missing components in the plan of care).
By default, this is set to ‘NO’. This means that the flowsheet preview (flowsheet summary of everything done for a particular date of service) is a separate, stand-alone document that can be printed and faxed separately.

When set to ‘YES’, the user will be asked to select a designated document type (initial evaluation, progress note, daily note, re-evaluation and / or discharge). One or more documents can be selected. Once selected, the flowsheet preview (associated with the same date of service) will also appear on the PDF of the selected document type(s). This applies to that particular user.

Let’s assume this setting is enabled for the daily note for the user ‘sam234’. When ‘sam234’ uses In Touch EMR, the enabling of this feature allows the user to generate and fax ‘combination PDFs’ that include the daily note and the flowsheet preview (associated with the same date of service) to the referring physician or payer. This allows the user to print and / or fax clinical documentation in addition to flowsheets (what was done) at the same time.

Referral Source Name on the Plan tab

it is important for users to see the name of the referring physician’s assigned to the patient while doing notes without stepping out of the note, so we added a new feature in the Plan section of your documentation, wherein you just hover the mouse on the Plan tab, then you will see the name/s of the referring provider assigned for the patient.