In the upper left corner is a drop down box that has the words New Assessment. This is the default setting, and this is what will appear every time this screen is opened.
Clicking on the drop down arrow in the New Assessment box provides a list of dates showing all previous assessments. To view a previous Assessment, click on the date and it will appear.
Under the New Assessment box is the Condition Status drop down. The Condition Status is a Medicare requirement and MUST be entered on EVERY visit. It is also a requirement of some State Boards. If the office does NOT work with Medicare, it is important to know the rules, regulations and mandates of your
To assess and record the current condition of the patient, click the drop-down arrow of the Condition Status box and select the Condition that most appropriately describes the patient’s situation.
Beneath the Condition Status box is the Progress drop-down box to choose the item that best fits the patient’s progress. As this is being written, the requirement for Medicare and State Boards is that the must be entered whenever a re-examination or re-evaluation is performed. The Medicare requirement for re-examination/re-evaluation is at least once every 30 days while the patient is under active treatment.
Any selection made can and should be expanded by further explanation. To the right side of the Condition Status box is the Resulting From checklist. After choosing the Progress level, move to the Resulting From box on the right. The Resulting From box lists phrases that complete the sentence that begins “The patient’s current progress is resulting from …”
In addition to choosing any of the items already provided in Resulting From box, there is the ability to add other items to this list. Simply place a check in the box on the last line next to the asterisk (*), click on the empty line and type in the necessary phrase. The entry will be saved when the window is saved. Although the phrase was entered in one patient’s file, it will remain on the list for use in any other patient account in which it is needed. The new phrase will also be added to the Resulting From box found on the Prognosis tab described below AFTER the patient file is closed and re-opened.
If the patient had a pre-existing condition, now is the time to record it. The Pre-Existing Contribution section has two parts. The box on the left has functionality similar to the Resulting From box. Select the item(s) that apply by placing a check in the appropriate box(es). There is the ability to add other items to this list. Simply place a check in the box on the last line next to the asterisk (*), click on the empty line and type in the necessary phrase. The box on the right is a text box for a larger, narrative style paragraph. Simply click your mouse in the box under Typewritten Assessment. Remember that data can be entered in this text box (and all other text boxes in ChiroPadEMR) by [1] typing it in, [2] drag and drop in from Paraphrase, [3] copy and paste from word processing programs, [4] dictate using Dragon Naturally Speaking, and [5] writing it on a tablet that has handwriting recognition which converts what was written into typed text.
When you have completed your assessment entries, save the information by clicking on the floppy disk Save button at the upper middle left of the window.