Fax Initials Note with airSlate SignNow

Fax initials note

hi this is David plait and what I'm doing today is showing you our physical new physical therapists the procedure when we're doing a new evaluation in our clinics using our program therapy source when we are have a new patient that's coming into the clinic what you'll notice on the computer on the left side of the individuals name you're going to notice a green box or a box that should be green when the patient has arrived when that person has arrived the front desk should have some information including the patient's referral as well as a medical history questionnaire once you obtain that information from the front desk in that file you can now check out your patient and then start a new note to evaluate your new client the first step in opening a new note for the patient is checking out the patient you'll notice on the top bar of the computer screen there's a box that mark that said States check out you're going to click on that button and you're gonna and it will open a case what you'll do next is go to another bar another button that's along the top that says new note I'm gonna click on that and then another box will open up this says patient documentation in this box you'll see that the button that mark indicates review diagnosis you're gonna click on that and now another box will open up in this section we're gonna confirm our diagnosis now where you'll find that is on the patient's referral so in this case it's going to be low back pain and when we confirm a diagnosis what we're going to do is we're gonna go to the right where it says status right now it indicates new we want to change that to either pending or verified verified is the preferred option and indicates that we do have the referral and that we are verifying that it is what we're evaluating if you did not have the referral in hand that you could put pending and then once the referral is in our hands then we could change that to verified so to continue on we verified our diagnosis you'll also notice in this box there's date of injury if there was a specific date that the person was injured we could indicate that here Sejal I will use an example of July first we could also put in something that indicates the date of surgery so we could put July 2nd for example these do not have to be entered when we enter when we confirm a diagnosis once we've confirmed the could diagnose see so we're going to go down at the bottom and click the ok button and then another box will pop up and it's going to indicate what note type we want to do when it's a new patient we're gonna click on the initial evaluation so I'm going to go down to ok and click OK now my notes going to pop up now you'll notice on the left side of the screen there's different sections as we go down there's our general info or subjective exam or objective exam our treatments assessment plan sketches charges and signature what we want to start with is in the general section this section can use be used for basic information including patients age reason for referral so if I click right down here reason for referral typically we're going to go to the other section maybe put low back pain possibly something with surgery so say status post lumbar fusion so that could be put in this section it also has a spelling check in here just click ignore we can also turn that off so click OK so now we have reason for referral low back pain status post lumbar fusion we have another box down below treatment guideline in this section we can put any precautions for example no lifting greater than 10 pounds and then I'm gonna click done the general section is mainly for just basic information that might give us quick synopsis or any pertinent information or precautions that the next person or therapist could use when they're seeing the patient you could also put occupation or cron or or the patient's age but those aren't absolutely necessary the next section that we're going to go to is going to be your subjective section and one thing I want to make clear is this computer program has a lot of information in it and people tend to over document when they use it so one thing that always helps is to use try to do what you normally would do and don't over a document so as we're looking on this screen we're gonna look for things like mechanism of injury so we can come down here mechanism of injury click on primary episode if there was just one incident you can add secondary tertiary or you can just go down to the other box so if we're gonna go to primary episode we could put gradual onset insidious we could put if there was a mechanism say they were you know playing different sports so Michael bicycling you could click on bicycling basically whatever you feel like you need to put in there to indicate how the injury was so we're gonna take out bicycling and just go with insidious so if I click the left arrow to come back my original column pops up over here so we've added mechanism of injury the next thing that we might want to do is chief complaint so the third section down on the left side of the lower screen you'll see chief complaint when you click on that you'll have another box pop up in the middle on your right there's areas as far as pain we can put pain levels we can put current severity maybe four out of ten we could just put severity at worse eight out of ten we can come down to aggravating activities we can click on activities on this next box over we could indicate sitting you could put a time down when I'm doing it I tend to go to the other box back here and what I'll do is just write it on one line so sitting greater than ten minutes possibly standing greater than one hour and then we're gonna click okay so we've got two complaints there you can either write your complaints on one line or we could split them up on two lines the other thing that we can put in there you'll see a still under chief complaint pain is the location of the pain if we look under the lumbosacral area we can click posterior and then it gives us different options left greater than right left right greater than the left right bilateral you can also go down to other there so we could say the pain is say right greater than left you could also add something like with radicular symptoms in right lower extremity and then click okay you could also write it as radiating lower extremity if you click on that box there you can actually put if it radiates from the hip down posterior Li or so the computer gives you lots of options once we've added our pain we could also we want to add goals to these different areas so for example we might add a goal to our current severity so if I click on current severity highlight that and then I'm going to go up to the top of my screen I'm going to make it a problem so you'll see the red flag on the top of the computer screen we're gonna click on that and then you'll see notice a white flag next to your chief complaint pain current severity four out of ten when we do that if we want to make it a goal what we need to do is go down to the bottom the bottom of the screen and you'll see add goal to chief complaint pain current severity four out of ten so what we need to do now is look on the list and we can say we can look under symptomatic improvements and you'll notice on that decrease pain to zero out of ten and we can make that a short-term or a long-term goal if I click on long-term goals that default is four weeks I can also change that to six weeks if I prefer and then I know I have my long term goal you'll see associated with the chief complaint current severity four out of ten my long-term goal is achieved in six weeks on August 26 2015 and the goal is symptomatic improvements decreasing pain to did zero out of ten I could also go down to chief complaint severity at worst and instead of creating a goal out of that I can just make it a problem so by clicking on this and just putting a white flag next to chief complaint that will cause this section this note this chief complaint to carry forward to our next note if I don't put a flag next to the information say for example chief complaint aggravating factors sitting greater than ten minutes this information will not carry forward to the next note so if there's any information that you put in your section in your notes and this in the subjective section or in the objective section if you don't at least put a white flag next to it creating a problem it won't carry forward you don't have to have goals for each and every one of them but if you want that information to go forward on every note there at least has to be a flag next to it so now we've got one goal set up at chief complaint pain current severity four out of ten and we've also flagged our chief complaints severity at worst eight out of ten now I'm going to make a goal for our chief complaint pain aggravating factors sitting greater than 10 minutes so again I'm going to go up to my problem button at the top of the screen I'm going to click on the red flag and then a new list will open up underneath what we want to go to now we could go to functional improvements I'm gonna go down to improve positional tolerance up to 1.5 hours click on long term goals and then I'm gonna change that to six weeks so now my goal for sitting more than 10 minutes and standing more than one hour I've added a long-term goal achieving six weeks on august 26 my functional improvements positional tolerance up to 1.5 hours I'm also going to add a problem to my chief complaint the location of the pain as well as the radiating pain one nice feature about this computer program is it gives you the feature to audit your note for example with Medicare there's going to be certain information that has to be documented for example rehabilitation expectations goals ADL functional status premorbid current status medical history questionnaires so you'll notice on the top of your screen it says note audit if I click on that it's gonna in a box will pop up showing subjective examination and right now we need to add documentation for our rehabilitation expectations I need to add ADL functional status premorbid I need to add something ADL functional status current I need to put the medical medical history questionnaire has been added in there and the patient has signed the consent form that's all in the subjective section when I scroll down a little further you'll notice that the objective examination there's nothing documented in there so there is mandatory documentation that we still need to do in the treatment section the treatment time still hasn't been done and we're going to do that at the very end and then the assessment we still have rehabilitation components 'real evaluation components client understanding evaluation components expected length of episode functional limitations these are going to be RG codes that we should all probably be familiar with and then we can also put in the assessment section that's not a required is presentation any impairments anything specific that you'd like the doctor to know and then you'll notice down at the bottom the plan we still have to put therapy to contact contents which is required as well as the frequency and duration of the treatment so I'm going to close this back out and we're going to come back up to the subjective screen that we're on and now what we're going to go through is some of those required areas for example the rehabilitation goals another box pops up you could go to eliminate pain and eliminate loss-of-function these are clearly up to you gives you many options you don't have to mark - these are just two common ones that I use next we're gonna go to ADL functional status premorbid you'll see they're in current status I'm gonna start with premorbid status so obviously this is before this person's Mindi samples back injury that she had on July 1st and her post her surgery so prior to her certain her surgery and her injury we're gonna I'm going to assume that she was independent without difficulty obviously this is something we're gonna ask the patient during the evaluation her current status we could put in work status basic care you'll notice and modified in but independence that says with moderates and some mild symptoms we can put moderate symptoms she's about a four out of 10 is what she's indicated to us okay the other part that we need to do is we look down on the left side of the screen the medical history questionnaire we always need to mark the medical history we've got that mark the patient signed it we've initialed it as well as the patient rights and consent another helpful box in there for a goal is the client knowledge and awareness of our home program that's always a nice goal to put in there you'll see client knowledge awareness click on home exercise program the patient lacks a program we're gonna create a problem out of that I'm gonna come down to client education and then independent with home exercise program I could write one or two goals associated with that I'm assuming they'll be here for six weeks so I'm just gonna change my long-term goal to six weeks and then click okay all right so if we go back up to our note audit click on that box again we look up in our subject of examination and everything that's required for Medicare has been documented in there so we know that's okay and we can close that box out and now we're going to go to our objective examination so again when you look on this there's a lot of information you do not have to use all of it again my recommendation is to do what you normally would do document how you would normally document so for example if I'm going to check somebody probably wouldn't check the range of motion but I'm going to show it to you anyway if we can check their patients range of motion I'm gonna click on range of motion and then you'll see a box on the middle column that says spine I can go to active lumbars lumbosacral their cervical you have cervical and lumbar and degrees cervical and degrees passive range of motion we're gonna click on active lumbosacral range of motion this section is in percentages so if I did measure this I could click on extension that first will say their 25% and then say their forward flexion was at 25% side bending right 10% and then side bending left 10% okay so now what we're going to do is we're gonna make a goal associated with our range of motion for active lumbosacral so again we're going to go up to our problem button at the top of the screen you'll notice the red flag next to it I'm going to click on the problem and then a white flag will pop up next to my range of motion active lumbosacral section that we just entered and now it's created a problem but it has not created a goal so if I want to create a goal for my range of motion I can go down to range of motion improvements go over to active lumbosacral range of motion I can go with a short term or a long term goal I'm gonna click on long term goal I can change that to six weeks or whatever I want click OK and now I can do one of two things I can click on within normal limits if I wanted let's delete that out of there we just got an error so hopefully you don't get an error I'm gonna go down to each one individually so if I have extension I can put that as within normal limits 100% maybe forward flexion I'm only gonna put at 75% side bending with the normal limits side bending right within normal limits so it gives you the capability of doing multiple things as you choose you can put in your own numbers or you can put in the default with the normal limits so now with our range of motion didn't create a goal so we need to create a goal again so go back to click problem again I'm going to go back to range of motion active lumbosacral long term goal I'm going to change that to six weeks or whatever I feel is necessary I'm gonna click on a hundred percent and then I'm gonna click done okay so now when I look at my screen I have got a goal because there's a green flag next to range of motion of the spine if I click on that flag you'll notice the long term goal has popped up and that's our goal for August 26 now we can go down through you'll see a number of different types of information that you could add there's observations you can come down to there's swelling generalized joint edema for something like a knee knee replacements posture is another one you could always go to other and just type in what you think on other palpation we might go to lumbosacral region palpation muscle posterior there's tenderness or swelling atrophy hypertonic spasm you can click on any of these types of things I'll click on tenderness and then a number of different muscles and the low back will pop up say we've got some tenderness in the erector spinae I can click on there click on no tenderness 1 out of 10 complaint of pain complain with wincing 2 out of 10 can go to wincing withdrawal will put 1 out of 10 I can change it side to side so on the left it's 1 out of 10 it may be it's on the right it's 2 out of 10 and click ok again if we want this information to carry forward to your next note we at least need to carry make it a problem you do not have to make it a goal though but you could it gives you other information in the objective section so we're going to go back up to our knowledgebase open that up again all of our information is on the left observation posture palpation range of motion muscle testing gait if I click on muscle testing I can come down to lower extremity manual muscle tests and then my lower extremity muscles will pop up we can do manual muscle it's on those for example hip abduction five out of five on the Left we can put four - out of five on the right I don't have to make a goal out of this I don't have to make a problem out of this if I leave it just the way it is muscle testing lower extremity manual muscle test will not carry forward to the next note this program also has you'll notice a little lower down on the column on the left we have special tests if I click on special tests I can go to the spine I can even go to the lumbar section of the spine and when I click on they're different difference but tests will pop up slump test can click negative on that if we had done that if we scroll down the screen you'll see straight leg raise negative it gives you different options or you can just write in what your option would be so I'm gonna put a problem or I'm not gonna flag that either let's see the next section that we're going to look at so we've gone through our general section general information we've gone through so here's our general information section again we've got our subjective section this is the information obviously we're getting during our subjective part of the evaluation our objective section here's some of that information the next column down we're going to see is treatment section so any treatments that you do for example patient family education maybe we're gonna click on that and we're going to talk about the pathology and the anatomy involved you can click on that you can write in additional detail be more specific you also want to make sure you keep track your time so if we did D is not a numerical values so we can put four minutes and click OK so we've added some patient education again in this section I can put more detail about what I talked about in the additional detail section we've talked about if there's modalities that you're doing you can click on modalities cryotherapy you can change that the location posterior changed the time that you do to 12 minutes click performed it also gives you this qualifier at the bottom of the box maybe you gave it to the person for a home exercise program I could click on that and click OK it also gives us manual intervention any soft tissue more soft tissue mobilizations possibly so with the low back we might go to lower quarter soft tissue we could go specifically into the erector spinae right there if we preferred or what I can do is go down to the bottom of the screen going to soft tissue mobilization and then just put a general region lumbar paraspinal z' i can click on there we can go to strumming or you could write in a specific one write your time down there 8 minutes and then click performed and then done so now that's gonna pop up on there it also gives you a list of exercises we can go to exercise activities any flexibility for example hamstring stretch right there we can change the time to 30 seconds possibly the repetitions to 2 I'm going to do a passive stretch possibly take with instruction to the patient in 3 minutes I'm gonna have them do that for a home program and I'm going to click done so whatever you do in this any treatment is gonna go in obviously our treatment section there's again a lot of information stick with what you do the next section that we're gonna go to is our assessments in this section especially with Medicare there's going to be certain information that we need to document so if I click on my note audit it's going to give me that information so evaluation component sorry a potential client understanding length of episode G codes and then I'd like to put in presentation so we can go to first presentation and then we can put in displays signs and symptoms of we could want or before that actually we could put science and symptoms consistent with referred diagnosed or we could come down to displays signs and symptoms of lumbosacral and I can put status post lumbar fusion low back pain whatever you prefer and then I'm gonna click okay so now our to get my spelling check is popping up in there and we can definitely turn that off because it has become a nuisance sometimes so we've got presentation symptoms consistent with referring diagnosan diagnosis presentation displays signs and symptoms of lumbosacral spines status post lumbar fusion low back pain so some of the other required sections that we talked about are going to be under evaluation components rehab potential physical therapy I'm going to put good you're going to determine that during your evaluation length of treatment I've determined about six weeks that we're going to be treating the patient client understanding I think they understand fairly well I might come down to impairments ADL's come down to flexibility pain range of motion if I did some strength testing caput weakness it gives you lots of options to go to our G codes we're going to go to functional limitations got a current status we're gonna go with about mobility and we'll put forty to sixty percent clinical judgment it's the objective units one and then click OK and now we need our goal status and we're gonna do this every 30 days so back to mobility walking around so we said that they're at forty to sixty percent so in another month I'm hoping that they're gonna be at least twenty to forty percent so that's what I'll put them at and click OK so now if I come back up to my note audit button I can see that everything in the assessment the required information is done the recommended documentation we do not have to do the next section that we're going to go to is our plan I'm going to do our frequency and duration I'm going to go change that from twice a week to a month click OK patient instruction goals and plan problems in questions problems and questions have been addressed patients been instructed in therapy dat contents might do some client education home education home exercise program I can click manual therapy I can put joint mobilizations I can put let's see we're soft tissue soft tissue mobilization some stretching therapeutic exercise can click on modalities here maybe we're gonna do a little bit of cryotherapy you can even go into electrical stimulation and be more specific so we'll just stop a cryotherapy so again I'm gonna come back up to my note note audit and then the only other thing that I have left to do is my required documentation is my treatment time and that's going to be in my treatment section so I'm gonna go back how much time did I spend with the patient we're gonna say 35 minutes click on their 35 done back to my note audit everything's done so once I've clicked that everything is ok I've got information on my general section that I need I've got my subjective section done I've got my objective section I've got goals and things flag that I want to carry forward I've got my treatment section done my assessment is done and my plan is done the next step is to sign the No so we're going to go to signature and then you'll notice on the top of the screen that says primary and secondary primary is what we're going to sign off on if we're finished with the note so what we'll do is click primary click continue and then we can check our charges will pop up on the screen it shows hot pack cold pack 12 minutes manual therapy eight minutes therapeutic exercises seven minutes and then the two G codes confer with that I'm going to click yes and then the next block box will pop up it'll say add second I'm gonna add my signature in and then I'm gonna click OK and then this box the plan of care will pop up this should be correspond with the plan that you put in the plan of the section we put in twice a week for one month I'm gonna say that's okay and then last thing that we're going to do is check in the note okay so we're finished with that note now the second note that we have on the screen is a daily No so this is the same patient that we just did the evaluation for now what we're going to do is we're going to pretend that this is a treatment that we're going to do so say the patient has just arrived in the clinic they've contacted you there's a green box you'll notice to the left of the patient's name that indicates that the patient has arrived so when we bring the patient back we're going to go up to the top of the screen we're gonna click checkout and then we're gonna go to the right of the checkout button and you'll notice a new note button I'm gonna click on that so once I do that a new note box will pop up I'm gonna click ok assuming that I want just a daily note and we're just going to ignore this box because we're assuming this is another day I'm gonna click yes and now every information that we flagged or made a goal for in our previous note will carry forward in the general sections subjective and objective so you'll see we put in referral reason for referral low back pain status post lumbar fusion treatment guidelines precautions no lifting greater than 10 pounds now I can go to my subjective section my goals have carried forward my pain scale my pain current severity 4 out of 10 my goal of aggravating factors sitting more than 10 minutes or standing more than an hour as carry-forward and then my home program goal you'll also notice that the severity at worst pain is carried forward but there's no goal associated with that and then also the chief complaint the location of the pain has also carried forward in this objective section these are the objective things that carry forward only the ones that are flagged the treatment section carried forward nothing in the assessment nothing in the plan so as far as a daily notes concerned once you open that note we can go back to our knowledgebase and that's going to be our KB button at the top of the screen I can click on that and I can put a daily comment you can put disposition how they're doing well today maybe they're stiff and sore today how they did in the previous visit increase the symptoms possibly then we're going to come back compliance with home program you can click on that there they're performing it as they are direct you're not performing as you can see performing frequently gives you lots of options one thing that's always helpful is if you click on the bottom of the screen are these other buttons if you don't want to try to look through and find things you can go to daily comments click other and we're just gonna write consistent with home exercise program and then click OK so I could click it that way so you have choices the other box is almost going to always be there in any section so there's my subjective exam if I measure something if I recheck some range of motion say in this second visit I can come to my box where it says extension there's a measure we measured extension now it's 50% I can click on that there I can click done I can come back up and I can actually change my goal a little bit to some progress so now I've updated my goal extension has improved to 50% we've changed the goal to indicate some progress and now we're gonna move on so in their treatment section only the things that you put in in the previous note are gonna pop up so if I want to add anything I can add more stretching say for example a stabilization exercise we go to stabilization supine we can come down to say a dying bug exercise and then we could add that in right there click perform you could add any additional detail 20 reps make it a home program click done if I do the hamstring stretch that we did in the previous visit if I did it exactly the same had them hold at 30 seconds repetitions two times we did it for three minutes I can just click on the box and it's done if I did something like soft tissue work but it last visit I did it eight minutes I did at 10 minutes this visit I can change it to 10 click done that carries forward at the end we can do our ice click on that and then we're done under the assessment I can put how they tolerated the visit same with mild complaints I could be more specific I can come down to our other box click on other and I can indicate the patient pain during the dead bug exercise period and then click ok and again the spellings popping up click ignore ignore so we've added to our assessment you could add any other information in this section obviously then we need to go to our plan what's our daily plan is it to continue with the current plan maybe we're going to progress with the addition of some more postural stabilisation neutral exercises for the next visit so again with this one we could also come up to our node audit I can see that I have two haven't documented my required documentation of therapy session time so with this if I come down to charges I can click on charges button and then everything that I've done will pop up so right now it indicates that we are at let's see 22 twenty-nine minutes of therapy so I'm going to go back to my treatment section I'm going to go back up to my knowledge base button and then there's therapy session click on the time total therapy session time 29 click done and now I can go back up to my note audit check that again it's out everything's done and now I'm closing my note so I'm going to click my signature click primary click continue check my charges click yes I confer with that now I'm gonna sign off again and then close the note check in and everything's done so you'll notice on your screen that when you're done with your notes they will disappear if I come up to instead of having incomplete it'll say all that my notes have now popped up and it shows with the green box a little check in it indicates that you're you've checked that one out off to the right where it says Associated no a closed envelope over to the right will indicate initial evaluation has been done and the daily note has been done you