Using Clinical Forms

Using Clinical Forms

Abstract

In a paper based chiropractic clinic, the practitioner will have forms to record their SOAP notes. Typically these include Chief Complaint, Secondary Complaint (sometimes known as In-depth Health Questionnaire), Examination Summary, X-Ray Summary, Diagnosis and Prognosis Summaries, and a Recommended Care Schedule. To assist in moving patient files out of the filing cabinets and into the computer, Capable 21C has the ability to store these forms and the resultant data for each individual patient. This article explains where to find these forms and how to use them in day to day patient care.

Underlying challenge

The challenge lies in flexibility. No two clinics perform exactly the same tests, or seek exactly the same subjective information. The role of Capable Software Pty Ltd is not to determine which is best and require everyone to use these forms. Capable 21C is instead built with the flexibility to allow you to tailor the forms to reflect exactly the tests you want to perform, record the findings in your preferred dialogue, and seek specifically the information you require from the patient. There is a separate Knowledgebase article (KB-Customising Clinical Finding Forms) which explains how to alter the forms in Capable 21C. However, understanding of the Knowledgebase article on altering forms will be greatly improved if you have read this article first.

Resolution

Many of the forms in Capable 21C use numbers and function keys to aid in the speedy entry of data. Most of the forms have been developed as a comprehensive list of the tests likely to be performed. As an example, the Examination Summary has around 350 tests you might perform in your initial examination. Each of these tests has a unique number associated with it. It is unlikely however that every clinic will perform all 350 tests. Our experience is that each clinic already has forms they use. Those clinics that are successfully using the clinical findings features of Capable 21C, use their existing forms. For each test on the form, the equivalent test in Capable 21C is located, and the number for that test in simply transcribed onto the examination form already in use. Some clinics laminate these forms and have them visible to the practitioner in the treatment room. Some clinics print these forms for every examination, and then throw them away once the data has been keyed. Some clinics laminate the forms and use removable whiteboard markers to record the test results. Once the data has been keyed, the sheet is then wiped clean. Once you understand how Capable 21C records the information, you will be able to determine the best way for your clinic to proceed.

The forms that exist in Capable 21C include:

Subjective - Chief Complaint

Subjective – In-depth Health Questionnaire

Objective – Exam Summary

Objective – X-Ray Summary

Analysis – Diagnosis Summary

Analysis – Prognosis Summary

Plan – Recommended Care Summary

Plan– Report of Findings Summary

To tailor a solution that works best for your clinic, we recommend you print these forms (see detailed instructions), and compare them to your existing forms. Transcribe the appropriate numbers on the Capable 21C forms to your existing forms. Keep (and use) your improved existing forms, and discard the oversized forms produced by Capable 21C. Also ensure that the description of the test result is consistent with how you record these. Identify any areas where forms will need to be altered. Don’t go straight to the Knowledgebase article on altering forms at this point. Continue reading this document first, as it will give you a much greater understanding of how the forms work before you attempt to alter them.

Detailed Information

For every form in Capable 21C, there is a form component and a data entry component. The forms themselves determine what data entry can take place. We recommend at this point that you print all of the blank forms in Capable 21C (if you have not already done so). You can then use these printouts to assist in the comprehension of the rest of this knowledgebase article, and also to assist you in determining which forms you desire to alter.

To print the Clincal Findings forms from within Capable 21:

Select File|Print Forms

To work through this knowledgebase article, you will need to print the following set of forms: /li>

Chief Complaint

In-depth Health Questionnaire

Exam Summary

X-Ray Summary

Diagnosis Summary

Prognosis Summary

Recommended Care Summary

Report Summary

If the required forms are not present in the list, Click the Change Default button, and one by one choose the report required for printing from the Select Items To Be Included column, and click the arrow to move them across to the Selected Items column. The form will then appear in the list when you select File|Print Forms.

In the Print Forms window, one by one, select the form and click Print. /li>

While you may recognize a need to tailor the forms at this point, please proceed with this knowledgebase article first.

In terms of data entry, all forms are accessible by clicking on the ROF button on the toolbar. If you do not have an ROF button on the toolbar, then you will need to add one.

To add an ROF button to the toolbar:

Select Setup|Setup Button Bar.

Click and drag the ROF button from the “Button Bar Options” window onto the button bar.

Close the “Button Bar Options” Window. /li>

To add a new ROF for a patient, or to view an existing one:

Click on the ROF button on the button bar.

Select the relevant patient.

Click OK.

The Report Wizard window will now be open.

You will notice that the Client Name and Case Number now reflect the name and client number of the client.

If you have previously keyed Report of Findings, the previous reports will be visible for you to select and view.

If you are entering a progressive review, click on the New Progress button.

If you are entering a new legal report click on the New Legal ROF button.

To view reports completed in the past, simply double click on the Report of Findings Heading to reveal the tests, and then double click on the relevant test.

If it is a new Report of Findings, click on the New ROF button.

When you click on either New ROF, New Progress, or New Legal ROF in the Report Wizard Window, a window opens which shows all the forms available for use, and any that have been completed in the past. To open a new form ready for data entry simply click on the Edit button beside the form.

To enter data into the forms:

Locate the required form using the steps above

For data entry on the Chief Complaint:

Chose the Chief Complaint from the Report of Findings Window by clicking on the Edit button beside it.

In the Chief Complaint form, the numbers you can see on the printed form are not used for data entry, and are there to indicate only the order that the sections will be presented in the data entry screen.

Each section will have the relevant responses listed as function keys.

For the Chief Complaint form, F2 defaults to entering today’s data.

Hence the first data entry will likely be F2, and then press Enter.

The next heading will appear above the box where the cursor is flashing.

Press the function key with the applicable response and press Enter.

If the response you want to enter is not assigned to a function key, you can type in the text manually for a one-off response, or click in the blank box beside an available function key and type the response there. Once assigned to the function key, the response will be available to select for all Chief Complaints in the future.

Continue with steps 5-7 until the last message box appears to say that the Chief Complaint is complete.

You can then place the cursor within the text box and alter any of the text.

If there is a second and subsequent complaint, click on the Next Complaint button and repeat the steps for the Chief Complaint.

When there are no further complaints, click on the Exit button.

At this point, the Report Wizard window is visible, but the Report of Findings window will be minimized in the bottom left hand corner of Capable 21C. Maximise this window.

You can proceed with other forms until all required forms are finished, and then click Save and Exit. Be aware that no forms are saved until the Save and Exit is clicked on the Report of Findings Window.

For data entry on the In-depth Health Questionnaire:

Chose the In-depth Health Questionnaire from the Report of Findings Window by clicking on the Edit button beside it.

Enter the code (listed to the left on the printout of the form) of the test you wish to record, and press Enter.

Capable 21C will then enter the wording for the test you are performing and the cursor will flash in the response box awaiting a response.

Click on the function key that most closely resembles the response.

If the response you want to enter is not assigned to a function key, you can type in the text manually for a one-off response, or click in the blank box beside an available or undesired function key and type the response there. Once assigned to the function key, the response will be available to choose from for all In-depth Health Questionnaire’s in the future.

When you have finished recording the results of the tests, click Exit.

Again the Report of Findings window will be minimised in the bottom left hand corner of Capable 21C. Maximise this window.

For data entry on the Exam Summary:

Chose the Exam Summary from the Report of Findings Window by clicking on the Edit button beside it.

The Exam Summary form works exactly the same as the In-Depth Health Questionnaire.

Each test has a number in Capable 21C. Key the number of the test and press the function key that most closely matches the response.

When you have finished recording the results of the tests, click Exit.

Again the Report of Findings window will be minimised in the bottom left hand corner of Capable 21C. Maximise this window.

You can proceed with other forms until all required forms are finished, and then click Save and Exit.

Be aware that no forms are saved until the Save and Exit is clicked on the Report of Findings Window.

For data entry on the X-Ray Summary:

Chose the X-Ray Summary from the Report of Findings Window by clicking on the Edit button beside it.

This type of form builds paragraphs within a report. It still uses the same data entry principles as the Examination Summary, except that you must click the Insert Code button (or hit Insert) before entering the code of the test, and there can be several places within the description of the test that may require you to enter data.

The cursor flashes at the data entry point and you key your result either manually or via a function key. Note that most function keys are not mapped in the X-Ray Summary due to the variable nature of results to be reported. You can still map them if desired by clicking on the blank box beside the function key and typing the response you wish to map to the key.

Once you have keyed the result, hit Enter again to move you to the next data entry point in the paragraph.

Continue to do this until the cursor flashes after a full stop, which indicates that you have completed the current test and will need to Insert the code for the next test.

When you have finished the report, click exit.

Again you will need to maximise the Report of Findings window, and either edit another form, or click Save and Exit.

For data entry on the Diagnosis Summary:

Chose the Diagnosis Summary from the Report of Findings window by clicking on the Edit button beside it.

The Diagnosis Summary works on the same principles as the X-Ray Summary.

Do not delete the ### at the start of some headings, as this will affect how the report prints.

For data entry on the Prognosis Summary:

Chose the Prognosis Summary from the Report of Findings window by clicking on the Edit button beside it.

The Prognosis Summary works on the same principles as the X-Ray Summary.

Do not delete the ### at the start of some headings, as this will affect how the report prints.

For data entry on the Recommended Care Summary:

Chose the Recommended Care Summary from the Report of Findings window by clicking on the Edit button beside it.

The Recommended Care Summary works on the same principles as the X-Ray Summary.

Do not delete the ### at the start of some headings, as this will affect how the report prints.

For data entry on the Report Summary:

Chose the Report Summary from the Report of Findings window by clicking on the Edit button beside it.

The Report Summary works on the same principles as the X-Ray Summary.

Do not delete the ### at the start of some headings, as this will affect how the report prints.

For data entry on a Progress Review:

Click the ROF button on the button bar

Search and locate the patient

Click on the New Progress button in the Report Wizard window

Follow the same steps as if for a New Report of Findings.

If revisiting the In-depth Health Questionnaire, Capable 21 will display the original report findings, adding a column for the progressive findings to be added to the report. If new conditions are reported these can be added to the report using the same technique as the original report, even though they may not appear in the original report.

Remember that as each form is completed, it is essential that you maximise the Report of Findings window from the bottom right hand corner of Capable 21C, and click Save and Exit when all reports have been entered.

If revisiting the Chief Complaint, a Select Progress Report Basis window will appear, and you can choose whether the Chief Complaint is subsequent to the Previous Report or a new Chief Complaint. Select the appropriate option and click OK. If your choice was based on a previous report, the original chief complaint will be displayed and new headings for Progressive Findings will be present. There are now only two new headings. The first is the date of review, and the second prompts a response that indicates whether the patient perceives they are getting better, worse, no change.

To Print ROF Forms for the client:

Click the ROF button on the button bar

Search and locate the client

Highlight the original Report of Findings heading.

Right Click and select Print.

Capable 21C will print all tests within the Report of Findings, including Progressive Findings if applicable, all onto one form for the patient.

Other Forms within Capable 21C:

The forms discussed in this knowledgebase article are not the only forms that ship standard with Capable 21C. There is also a Questionnaire (which you can add to the button bar), that the patient usually completes. Note that this is the only form in Capable 21C that is not alterable. Also, by clicking on the New Legal Report in the Report Wizard, you can create legal reports. The legal reports work on the same principles already noted in this knowledgebase article, and can be printed from the Print Forms option.

Editing Clinical Findings Forms:

It is important to now recognize that all the data you see in both the blank forms, and in the responses that can be keyed, are completely customisable. (With the exception of the Questionnaire, which is NOT the In-depth Health Questionnaire). Every single word is customisable. If there is an existing form that you would like to tailor and print for use in your clinic, refer to the knowledgebase article KB-Customising Clinical Findings Forms available in the FAQ section on our website.

What about images on your existing forms:

Some clinics have images on their clinical findings forms that are used in the recording of SOAP notes. Usually this is an image of the body, and usually there are either circles or lines drawn on the body. Currently there is no way to integrate graphics into the Report of Findings module in Capable 21C. There is however a full body tab within the Visit Notes screen, which would allow you put circles on the image, and where you would normally put a line, you can put two circles that indicate the trajectory of the line.

Alternatively, you could consider laminating your existing image, using a whiteboard pen to mark the image and then scanning and attaching this to the Visit Notes screen.

A feature enhancement to allow straight line and circle drawing facilities within the Visit Notes screen is pending.

This knowledge resource is designed for use on a Windows (tm) XP system operating at a screen resolution of 1024x768 or better. Windows Media Player must be installed for this training resource to operate correctly.

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