Using Templates to Write Comprehensive Assessments
February 8, 2018In: Therapy Documentation Resources
You’ve collected a case history, completed observations, conducted assessments, and diagnosed a patient. Now, it’s time to write up an assessment report, which can be a daunting task at times. In addition to saving clinicians time when writing assessment reports, ClinicSource therapy EMR software templates help therapists create robust reports that meet insurance requirements for reimbursement.
Assessment templates are discipline-specific. This saves clinicians time, as they no longer have to sort through tests, checklists and factors that are irrelevant to their disciplines. Therapists only view information that is important to their specific practices. As a result, clinicians spend less time sifting through unnecessary items and more time creating relevant assessment reports.
Pre-formatted templates ensure that no detail is missed. By using templates, clinicians ensure that all aspects of an evaluation are documented. ClinicSource therapy EMR software templates walk therapists through various components of an evaluation, reducing the chances that key information may be accidentally omitted or overlooked. Therapists enter information into clear and distinct portions of a template, including case history, standardized assessments, observations, and conclusions/recommendations. In turn, therapists can create assessment reports that are thorough and easy to read, increasing the likelihood of insurance reimbursement. All templates are automatically updated as regulatory changes occur, ensuring complete compliance with insurers such as Medicare and Medicaid.
Templates are structured, yet flexible. ClinicSource EMR templates can be customized to include a clinician’s specific preferences and needs. Therapists can easily create or modify templates to include all aspects of an assessment that they deem to be important. Want to include a document or assessment that is unique to your clinic? This task is easily accomplished with customizable templates. Additionally, clinicians can add, move, or delete items within a template, ensuring that only important information is captured.
Pick and click only what you need. While there are a wide variety of assessments and profiles available, therapists can selectively choose which EMR templates they wish to activate, and not experience clutter from what they don’t need. Simply click the standardized assessments and tests you want, and ClinicSource drops the scoring grid into the template. And ClinicSource therapy EMR software automatically updates at no extra charge, adding new templates as new versions of assessments and specialty-specific templates are released.
Create alerts to track timelines. Once an assessment has been completed, it is important to be mindful of dates and timelines for a reassessment. When creating the header for an assessment, clinicians have the option of entering a date for reevaluation. After the initial report is completed, an alert is automatically set to remind clinicians to conduct a re-evaluation on a specified date. By completing reevaluations in a timely fashion, clinicians reduce the chance of insurance denying unauthorized claims.
Clearly document conclusion and recommendations. Clinicians can easily document their clinical impressions to patients, physicians and insurance companies. Additionally, therapists can make clear recommendations regarding the amount of treatment suggested and referrals to other therapies or medical specialists. ClinicSource therapy EMR software makes it easier than ever.
No time to finish an assessment in one sitting? No problem. ClinicSource EMR templates allow practitioners to save their work and return to it at a later time. This gives clinicians the freedom to complete an assessment report in small pieces or in one sitting. It also provides clinicians space to write their reports and come back to review their documentation at a later date prior to signing it. Plus, a handy autosave feature ensures that ClinicSource automatically saves your data inputs whenever new activity is detected.
With busy caseloads and documentation demands, clinicians who take advantage of templates save themselves time and money. By using ClinicSource templates, clinicians can reduce the amount of time spent creating reports without sacrificing the quality of their documentation.
Click here to learn more about ClinicSource, the cloud-based EMR software for therapy practices of all types, including Speech Therapy (ST), Physical Therapy (PT), Occupational Therapy (OT), Mental Health (MH), Applied Behavior Analysis (ABA), and pediatric therapy.Let Us Show You