Clinical Forms

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In This Section

Initial System Setup


Appointment Type Templates



List Maintenance

  • Form templates are designed to enter information into the system in an organized way. They are composed by one or more "Form Sections", which are identified in EMR-Bear as pages or models.
  • EMR-Bear offers many models that can compose a form needed for data input. If EMR-Bear lacks a field to capture a specific data set, the Custom Models can be used to generate any desired type of input into the system. In the event that EMR-Bear lacks a field to capture a specific data set, the programmers will work to get that field included either inside an existing model or into a new model.
  • Admin rights are needed to access the Form Administration page in the system.
  • Go to Dashboard -> Clinical -> Forms
Form 01.png

  • A screen will open with a list of pre-loaded forms that can be viewed, edited, changed, or deleted entirely. Note that the icons will not appear until you scroll over a particular form. Below is an example of what the Form Templates page will look like. To add a new form, click the green Add New Form button.
Capture Form Templates.PNG

Defining New Forms

  • The Forms are defined in two steps.
    • First, define the Form as a whole and assign properties that are unique to that form.
    • Second, assign the models or pages to the form. By assigning the models, the form is constructed to capture specific information. For instructions on how to add or modify form models go to the section, Adding or Modifying Form Models at the end of this section.
Capture New Form Screen.PNG

Explanation of Form Fields

  • Title: This is the form heading. It will display at the top of the form when viewed on screen or on pdf (e.g., Initial Assessment).
  • Alternative Titles: This option allows the form to display a different title. If Alternative Titles are included, a menu with the Alternative Title choices will populate when the Superbill is presented to the User. If a title other than the default title is chosen, then that title will display at the top of the form.
  • Due From Enrollment (days): This field can be blank or enter a number representing the quantity of days for that form to be filed from the client's effective enrollment date in a given program. If completed with a value, the client's chart will provide visual clues in terms of timely completion of the form.
  • Recurs Every (days): (repeat after) This field can be blank or enter a number representing a quantity of days. When a number is entered, the system prompts with visual clues that a form needs to be furnished again for a given client (e.g., if 365 is entered, the form would need to be re-assessed every year).
  • Billing Codes: This field can be blank if no Superbill will be furnished when completing this form. If a procedure code is likely to happen upon completion of the form, then the accepted billing codes offered in the Superbill form have to be entered here. If more than one code is entered, then they have to be separated by commas.
  • On complete notify to user: In certain cases, a User of the system might need to be promptly notified when a form is completed. If a User is entered in this field, that User will receive an internal intercom (message) stating the form was completed for a given client.
  • Show App info in introduction: Checking this box displays appointment information in the introduction of the form.
  • Show App Duration in introduction: Checking this box displays the duration (in minutes) of the original appointment at the top of the form.
  • Show Client SSN in introduction: Checking this box will display the client's SSN in the form introduction.
  • Show Location in introduction: Checking this box will display the encounter location in the form introduction.
  • Show Superbill Start Time in introduction: After the Superbill is completed, the start time will be included in the form introduction.
  • Show Superbill End Time in introduction: After the Superbill is completed, the end time will be included in the form introduction.
  • Show form in all audits regardless of program: If this box is checked, when an auditor visits an auditable record for a given client, forms that are marked as such will be included in the audit report, regardless of the program the auditor is reviewing documents for.
  • Show Client's DOB in form introduction: The client's DOB will be included in the form introduction.
  • Show Type of Contact (TOC) (CCSS): Checking this box will display the Type of Contact in the form introduction.
  • Show SB POS on introduction: The Superbill Place of Service will be included in the form introduction. If several procedures occur in the Superbill POS, it will default to the first POS of the first procedure.
  • Required: This field is not significant yet and can be left blank or checked without changing any behavior.
  • Show Payor: The Payor name will be included in the form introduction.
  • Show Signature Time in signature: Checking this box displays the time at which the electronic signature was executed. This will be rendered in the pdf document that the form produces.
  • Show Sig Cert Description in signature: Checking this box displays the initials of all the certifications on file for the signing User. Certifications will follow the User's signature (e.g., PhD, MD).
  • Show Sig User Title in signature: Checking this box displays the full description of all titles for the signing User. Titles will follow the User's signature (e.g., Medical Doctor).
  • Show optional pages in form: Checking this box displays the optional models in the form. This is better understood when adding models into the form.
  • Needs Mgmt Review: Checking this box will require that the form be signed by a User in addition to the Clinical Supervisor. This might be required for billing purposes and would prompt a signature from a Clinical Director or Location Manager of a particular program.
  • Add to PCP Fx Option: The form will be included in the drop down "Send to PCP", this is a work in progress feature.
  • In Menu: Doesn't apply yet.
  • Telemed: Checking this box will affect the billing behavior of the form, creating two instances of billing Superbills, one for the Telemed session, one for client services.
  • Is this form used for MD eval?: If the form is used for med eval, some analysis logic will be rendered on the Superbill to help with the coding.
  • Launch w/o app: Checking this box allows the form to be launched outside the context of an encounter or an appointment (e.g., Notes that a provider might want to add after a phone contact).
  • Show admission date: Checking this box displays the program enrollment admission date in the form introduction.
  • Show discharge date: Checking this box displays the program enrollment discharge date in the form introduction.
  • Send to PCP: this is a work in progress and not active.
  • On completion, Auto Enroll in Program: when a program is selected, whenever a form is completed using this template the system will attempt to automatically enroll the client in the given program.
  • On completion, Close Program: Selecting a Program from the drop-down menu prompts the system to close the Program associated with that client upon completion of a form using this template.
  • Duplicate Models?: This offers a drop-down menu displaying the forms that already exist in the system. This is a time saver when creating forms that are alike but differ in only few models. Selecting an existing form creates a template for the new form, which can be adjusted by adding or removing models from it.
  • Instructions: This displays information to the system Users before launching the form. Use this space to enter as much text as needed to give information about furnishing this form.
  • After you define the main characteristics of the form, you will need to add models to the form template (or add/remove if you choose to duplicate models). We recommend reading the Prebuilt Models and the Custom Models section of the documentation before proceeding with adding models to the Form Templates.

Prebuilt Models

  • Form models, pages, or form sections are the units used to build up a form. EMR-Bear has more than 200 models available and keeps adding them as the need arises.
  • Documentation about each model is provided separately. It takes some time to get acquainted with each model's documentation capabilities. Some models are plain text data entry fields while some others have complex interactions with data in the system or with other models.
  • The best way to understand and fully train on each model is to create a form that has every model on the system and therefore allows opening each of those models in a single environment. Depending on your contract, EMR-Bear provides a Sandbox System for trainees to practice and refers to this form that includes all models as the "Master Form".

Adding or Modifying Form Models

  • Although the process for adding models to a form is fairly simple, determining which model should be part of your form might not be as simple. Familiarizing with the models is very valuable when it comes to creating forms.
  • To add models into a form click on the link next to the form that reads "Models".
Form 04.png

  • This opens a window that details the Models for a particular form (we are using the form for BMS Discharge Summary).
Capture Form Model Screen (2).PNG

  • This form has 3 models that make up the form. They are Form Introduction, Discharge Summary BMS Discharge Summary, Superbill, and Signature. Note the positions of each model, which allows the addition of other models should the need arise. The box at the bottom of this page allows you to enter additional pre-existing models from the Page or Custom Model drop-down menus.
  • The bottom part of the form will look similar to this:
Form 05.png

  • Page: displays a drop-down menu listing all the models available in the system.
  • Position: sets the order on how the models will be displayed in the screen and in the PDFs.
  • Validate: this check box does not have an enabled function yet.
  • Optional?: tells the form whether it can be signed or not without completing the model. For example, if a form has a model "Mental Status" and it is checked as optional, then the practitioner will be able to sign the note for completion without completing the "Mental Status" model. If the same form has the check box for the model "Mental Status" unchecked, then it means that it is mandatory for the practitioner to complete the "Mental Status" model before signing the form.

  • The form will accept a signature depending on whether the mandatory (non-optional) models have been completed or not.
  • Most forms should start with the "Form Introduction" model first. The form introduction will create the header and display the date and appointment information.
  • We assign the position "10" to show it first, as all other position numbers will be in multiples of 10. Using multiples of 10 allows you to insert a form later that you might want to view ahead of an existing form (e.g., using position 9).
  • When the form is created, a new screen will show the progress in the form. At the top of the page, the models that are already in the form will be displayed. At the bottom of the page, the same form is used to add more models to the Form.
  • A good practice would be to add both the Superbill model and the Signature model with high position numbers so they will be situated at the end of the form. As models get added to the form the view changes to show the current models inside the form.