Maximizing Documentation Efficiency
Hello, everybody. Good afternoon. We all know the documentation has the potential to be time-consuming. But luckily there are offices been built with plenty of features to help you increase your efficiency and maximize the time that you spend documenting so you can spend less time doing data entry and more time treating your patients.
So today we’re going to go through an initial evaluation using all of our efficiency tools to take a look at just how efficient you can be going through these documents. with that you’ll see right here. We have a document organizer for this patient who’s being seen for the first time. Mr. John Doe.
You’ll see when we click on our document organizer here. It’s going to pull up this window that populates information from the schedule about what is actually going to be on this note. So you’ll see the document type is selected for us as well as the date all of the case information the times that the patient was Dean and even the provider who is seeing them today.
Mr. Doe is going to be seen with me. We’re going to go ahead and click OK here. And it’s going to pull all that information from the schedule and help us create a document right now. We’re in the document editor, which is where you actually begin to edit all of your data and right away. The first thing that pops up is this document template window document templates can be a really useful tool to help you populate information sets not patient specific but maybe specific injuries TheraOffice for example comes with all of these different document types here.
And different templates that you can use to populate information based on injuries. In addition to the ones that are pre-existing. You also have the option to add your own template. You can create one from a blank start. So if you want to go through and put it together from scratch you have that option or if you ever create a document that you think is just the perfect document and all documents.
You want to keep using it from now on. You have the option to copy from a current document so you can save that one for future use. We’re going to come down into our shoulder template here, and we’re just going to make a couple edits to make this one useful for our process and for our practice. So we’re going to highlight the template and we’re going to come up at the top and select edit.
Now you’ll see in this document. You have your template editor that will allow you to edit all of the different parts of our templates from the sections that we’re going to be using all the way down to the information that will pre-populate when we actually apply this template. Now today the change that I want to make is adding these BMI and follow section to these notes automatically because my clinic is participating in mips and I want to make it easy on myself.
So I don’t have to keep clicking it each time. But of course as you’re going through these feel free to make any changes that you want to see reflected in your future now, That could be selecting your section. You can choose the information that’s going to populate with then all of our boxes or you can even go through and fill out some of these tables ahead of time the important thing to keep in mind as you’re editing.
These is that this is going to be applicable to all kinds of patients. So you always want to make sure that if you’re setting up your template you’re filling them out with information that specific to your practice and to your style of. Without being specific to your patients. Now we’re going to go ahead and save the changes that we just made on our template and we’re going to come through and actually apply this one to apply the template.
All you have to do is double click and you’ll see it fills out information from the template into your note. Now that our templates filled out some non specific information for us. We’re going to go through and fill out some information that’s relevant to our actual patient. Over here in the document navigator to the left.
You’ll see you have this tree option to help you navigate through. Through so let’s go ahead and start filling out some information for mr. Joe. Once you filled out a section, you have the choice to either click next here at the bottom of the screen, or you can come over to your tree on the left to navigate to the next one that’s going to be completely up to you as you’re going through it.
We have our faults section here. Mr. Doe is not a Falls risk, and he’s actually under the age of requirement for it. So we’re going to go ahead and select no.
Our next section is our current condition. And as we’re looking at this you’ll notice this is where our patient specific information starts to come in. So we’re going to go ahead and start filling it out. Now all of our boxes here and there are office are free text boxes. So as you go through you have the option to come in and type in each of these boxes, but in addition some of the other boxes have some tools to help you get through them a little faster this box for example has a drop down now you can use these dropdowns to populate really any sort of information you like here because it’s onset date you’ll see all of our dropdowns are specific to date.
And then of course if you have a lot of them and you’re looking for one, you can search for a specific drop down. This one also has a handy tool here in that you have this date picker,
which will allow you to pull up a calendar to actually select the dates that you want to fill out if you know the specific one. And then of course because this is Sarah office and we’d like to make things flexible for you any place that you encounter a drop down in these notes is going to be completely customizable every time you see that drop down keep an eye out for the little Ellipsis button when you click that ellipse button, you’ll see it pops up this drop-down list and you can create your own custom drop down to use in future notes.
We’re going to go ahead and save it and let’s use our custom drop down. Going through our next sections here. You’ll see we come to this table cables are going to be some of the most common elements that you’re going to encounter documentation and they’re built with some pretty useful tools now, of course.
You have the option to come through your tables and use them as free type text boxes. But within each table, you’ll also find that there are drop downs just as we talked about before all of your dropdowns are completely customizable. So keep an eye out whenever you see a drop down for either an ellipse or at the top of the table, you’ll notice there’s a customized dropdowns button.
Moving into our next section here pain history, you’ll see we have lots of tables again, of course in our table drop down and customizations. But this one’s a little special because you’ll notice it has these documentation pop-ups. These pop-ups allow you to visually select pain areas rather than having to type them out or search for them in a drop-down.
Now, of course, if you decide that you don’t like these pop-ups and you would rather enter it in manually or use those dropdowns. You can control that using your document settings in our backstage menu, you’ll find documentation settings and you’re able to turn off your pop-up. Moving into our next section here in her functional status.
I’d also like to point out another tool for you in your table. Now this tool is going to be super useful when you’re adding multiple items at once and you don’t want to go through each one individually. You have this add items tool in your tables. When you click on ADD items. You’ll see it gives you a list with check boxes where you can add multiple items at the same time without having to search for each one.
Within this, of course, it’s easy to make mistakes as you’re going through documents. So, of course you want to be able to remove those easily so you can always use this delete item tool from up at the top.
Coming into our next section here is our medical history. You’ll see you again. We have three individual tables each one with the same tools. We noticed before. For you also have the option in your medication history if your clinic is participating in maps to rather than filling out this table upload this list as an image note.
If so, you have the ability to check the attest to current medications being documented in image note button rather than having to enter them in manually here. That should help you save some time. If you’re going through this list, though. Of course, if you prefer, it’s just a table. Lots of tools doesn’t have to be intimidating.
Another thing. I want to point out to you on this screen are our common phrases. Common phrases can be used to populate information into comments or freeform boxes to allow you to populate full sentences sentence starters anything that you find yourself using commonly to apply a common phrase.
You’re just going to double click on the phrase and you’ll find it shows up in your comments box. Now, of course, you’re common phrases are again completely customizable. So you have the option to come in and add your own phrases if you’d like or you can edit the existing phrases if there are phrases that you find you don’t use commonly, you have the option to come through and delete them.
Moving on to our next section here is our observation. You’ll find again. We have lots of common phrases available. Now these common phrases are interesting because they’re actually sorted by categories here allowing you to locate the ones that you’re looking for quickly. These categories are selected for us by our template.
So, of course as you’re going through and creating your templates, it’s a good thing to keep in mind. What categories you’re looking for. Skipping down our patient Navigator here. You’ll see we have the shoulders section expanded to show us all of the additional sections for it without having to click into it.
Again. That was something that was done by our template. But if you ever need to expand or retract the section you can click these little triangle. Looking at these section our template pre-populated the normal measurement. So you just have to go through and populate information. That is abnormal.
If you have sections that have lots of the same entries you have the option to select it highlight the box that’s going to be the same and we’ll select copy two columns. You’ll notice when we copy this is the column it drops that information all the way down. So rather than having to enter it multiple times you can cut it down to one click and save yourself some of that entry.
Coming back down through our sections again. You’ll see those normal measurements you come through and populate. What’s abnormal?
We’re going navigate down through our document Navigator here to palpation and you’ll find again we have our common phrase boxes. In assessment, it’s again another table. And this one you’ll notice has an additional comments boxes that you can choose to use. Pointing out again. We have our drop downs which are completely customizable as we’re going through this.
I’m sure you’ve noticed a trend that. Part of what makes documentation efficiency possible is the customization that you put into your document. So if you put in a little bit of work here at the beginning to make sure that you have the options available to you to make it easy you’re going to end up saving a lot of time down the line so it’s worth putting in a little extra.
Coming into our problems section. I want to point out another tool to you and your table you’ll notice we have these little arrows that you can use to move things up and down throughout the left reordering them in a way that makes sense to you.
Coming down through goal here. You’ll notice our headings on the table have changed from the headings that we were seeing before where before you saw add items now in gold is going to be more specific. So you have ADD goals. You can come through. I’m use your check boxes, or you can use your drop down.
Within a treatment plan. This section is typically used to help generate your plan of care. And one thing that’s really important to keep in mind is that you always want to make sure that if you do plan to recommend PT you check off this little recommend PT box. It’s easy to miss. It’s up there at the top.
But that is the box that will actually push this. From your data onto your report which is how we generate our plan of cares. So this box is going to be extra important to you as you’re going through in generating that. Now we’re going to come to our initial treatment page which is of course one of the more important pages of your eval.
You’ll notice right away up here at the top. We have this evaluation complexity. This wizard is triggered by using the 9 7 0 0 1 code for your evaluation, which is the old code and requires a complexity information. You’ll notice if we change this code. Our wizard will go away. That’s because the complexity has already been chosen.
Now, of course, you have the option to come through and select that complexity yourself or if you prefer to go through the wizard changing it back to nine seven zero zero one. We’ll bring our wizard back up. You’ll notice as you go through your wizard selecting your boxes, it will change the code down here for you so you can make that judgment easily.
Within the treatment you also have these columns up here at the top with the not set information the not set buttons here allow you to select information that would normally show up on the right of the box over on the left. That way you can kind of cut down on the navigation that you have to make throughout this page and allow yourself to just make a couple quick clicks on the left rather than the right if you prefer.
Now you’ll notice when we clicked on our first not set button. It opened protocol Protocols are used to separate treatments that are all relevant to a specific injury together. So for this patient, for example, we’re going to pull up our general shoulder protocol and you’ll see we have a list of treatments that have been set up here that follow that typical protocol.
Now for mr. Doe we’re going to do all of these treatments. So we’re going to go ahead and use this talk checkbox to select all we’ll hit OK and you’ll see it as each one of these treatments into our note as being performed with mr. Doty. Protocol can easily be set up through your backstage menu documentation protocols.
If you decide not to use a protocol you have two different options for finding treatments that are outside of those. The first one is this find option, which you’ll see allows you to search for your different treatment where list has them sorted out for you by the different types? You also have the option to use progression to follow you throughout the changes of your treatment progressions do require a little bit more set up at the start, but they allow you to make fewer changes down the line as these treatments are carrying throughout your treatment plan with the patient.
So maybe today we want to do one set of 5 with mr. Doe but in our second treatment with him, we’re going to do two sets of five. You can use a progression to set that up for you. So it switches without you having to move it. Looking here, you’ll notice you also have the status has available. The reason why we have these statuses is because of active data active data pulls information from one note on to the subsequent note.
So rather than having to re-enter that information again, you have it already pre-populated in your note because treatments are one of those things that tend to come up frequently throughout the course of treatment with a patient. You have the option to change the statuses. Not performed if you prefer not to perform it with the patient today, but you want it to continue to carry through your treatment.
Moving down into our next section here. We have our functional testing. You’ll see I’ve populated the Spady test in this document though. Of course, you have the option to add any of the functional test that you have set up in your therapy office. As we come through we’re going to add in a school or for our patient and you’ll find that because this baby test satisfies the requirements for both pain and functional assessment.
Both of these sections have changed the green check indicating that we’ve satisfied that requirement. moving here into our next section. We have our charges. You’ll notice charges have three different tables here. The first one being the charges of typical CPT codes. These are what are going to get pushed forward into accounting and build out.
You also have this table to record your functional reporting charges and your lips charges. These two bottom tables are going to automatically populate for you with the information that’s pulled from prior places in the note. So you’ll never have to worry about entering in those charges yourself manually CPT codes of course can be a little tough to keep track of especially when you have those fee schedule.
So as a tool to help make it easier for you. We’ve built in this suggest charges, but. Suggest charges will pull information from our initial treatment page. It pulls the treatments we’ve done the codes are pulled to matches them up with the fee schedule that the patient is on and it suggests the correct number of units based on the minutes that we spent with the patient.
We’re going to go ahead and hit OK here because our two units is correct and you’ll see you get a pop up indicating to you that the treatment time is different from the minutes between our time in and time out. This pop-up is to help keep you from under or accidentally over billing and you’ll see you have the option here to adjust the time in and time out.
In order to make sure that our note is correct with our check complete you’ll find it’s pre-populated our GP modifier for us and we’re going to go ahead and generate our document report these documents reports include. Your plans of care, you have the option to use it an initial evaluation or you can even generate a home exercise plan for your patient.
Today because we’ve just done our initial evaluation. We’re going to go ahead and select the full initial evaluation report type. Type, of course, you have the option here to decide whether you want to go ahead and save the report without opening it or if you prefer to review the report before finishing you have the option to select edit and word processor.
I’m feeling pretty good about my data today. So I’m going to go ahead and choose to just save the report. Down here. We also have our document reminders that you can use to remind yourself of things that are either within a certain visit range or within a certain date range today. I want to remind myself to do a plan of care in ten visits.
So I’m going to go ahead and leave our documents and reminders on we’re going to hit okay. And you’ll see if we get the save report as window. This will allow us to name our report as well as have the option to choose what happens after we save this report. The first two options will just close it and will not lock the document data.
The first one allows us to close to the word processor allowing us to see that report. The second one will save the report close the data and open back to the patient Navigator so we can continue working in his file. Our bottom two options are actually going to lock our document data, which pushes the charges forward to accounting and also prevents any of this data from being changed down the line.
There’s third option here locks that document data and closes back to the pitching Navigator. If you want to continue working at his file where the bottom one will lock your document data and then close to the clinic Navigator after saving which will allow you to come back to your home screen and continue working through other patients today.
I’m going to close back to the patient Navigator because I’m not quite done with mr. Doe yet? We’re going to click okay? You’ll see it’ll run through the list and it’s locked our data and generated a report for us. With that we are all finished with his initial evaluation. It was quick. It was easy.
It just required a little extra work on the outset now in our subsequent notes, you’ll notice we have that active data we mentioned earlier which is information that pulls forward onto the subsequent know. So rather than having to re-enter, mr. Jose information, every single time are active data carries it Forward on to the next one and you’ll see you don’t have to enter the same information.
You just change your statuses as necessary. Change things according to the actual treatment you did with the patient without having to start again from scratch. A little prep work at the outset can save you a lot of work done line. I hope you learned something useful about documentation today. I’m you feel empowered to maximize your own efficiency as Don mentioned earlier.
We’re going to be taking questions for the next several minutes. So, please feel free to send in any questions or concerns you might have. All right, and we are back you guys have some great questions. So thank you for submitting all of those. Our first question is about dragging the speak. They’re asking if it’s compatible with Sarah office the answer to that is that it is we have quite a few customers who utilize Dragon speak and they seem to really like it.
So it’s going to be up to you and what works for you as a therapist and for your clinic, but it is an option. The second question asked about the owners of customization. So opening this document up here. I’m going to pull up one of our customizations. You’ll see on any of them. You have the option to set an owner so that it’s specific to just one person.
If an owner is set. It means that that one person is the only one who can edit use or even see that customization and Sarah office. If you prefer to leave it accessible for all users throughout the database you can leave that owner as blank and then any user in TheraOffice has the ability to edit utilize delete that customization that’s going to be the case for your common phrases your drop-down and your templates.
So it’s something to keep in mind as you’re going through and building them out. Our next question asks about adding a charge to a note after it’s already been locked. Now. There isn’t a way to go through and change charges in locked data. However, you do have the option to do what’s called adding an addendum to an addendum.
You have a couple of different options. The first one is to come in through a report. Reports are just word processors. So you have the option to open your report make the changes you can add a charge in here. Name the report indicating that it has a change. I like to always add the word addendum to the report and save it and then you’re going to go through into your accounting manually add the charge.
And it will be reflected in your documentation.
Our next question asks how to access templates the answer to that is through the actual document editor rather than through the dock designer. Are so I always like to edit my templates in a test patient, but for our purposes we’re going to use. Mr. Doe today. You’ll see in your document editor. You have this top toolbar with your document template.
You select the template that you’d like to make an edit to hit edit up here at the top and you’re able to come through and make your changes. Our next question asks about the default to recommend PT. We would definitely recommend setting that default. Here in your template you can check off or uncheck recommend PT and when it fills into your documents later, it’ll already be checked off for you if that’s what you’d like.
Our next question asks about how to open an image note image notes are fortunately very easy to open once you know how to do them. You’ll come to the patient Navigator. select new document. I’m down at the bottom. You’ll choose image note. You want to name your note click. Ok? And you’ll see here.
You have the option to import a file from your computer or you can directly scan one from any Twain compatible scanner. Once that image is actually in the note. You’ll go ahead and click save and you’ll have it in the patient’s file. If you’d like, you also have the option to come through and lock that document protecting it from accidentally being deleted.
Our next question asks how to see faxes that have been sent out those faxes are accessible from your inbound Q, which is available in the Home tab. your inbound to keeps a list of all of your incoming and outgoing faxes. Now this is just our test database. So it’s not actually configured for faxes.
So this one is a little light, but you’ll see if you’re sending faxes out. They will appear here. It will indicate the patient’s name and the date that it was sent out. So if you’re ever looking for something specific, it should be a quick find. Our final question for today was about MIT. They asked about the nip pop up that shows up every time they log in if your clinic is not participating in myth and you’d like to stop that pop up from coming up you are going to login under the administrator come to the backstage menu select administrator.
I’m down at the bottom. There is the myths configuration wizard. You can run through this wizard to opt out of the mips program that will keep that pop up from continuing to pop up for you as well as have the program know that you are not participating in mips for the 2019 reporting here.
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