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1. 3 Resident 072 Years a ey CT gt Es Patent ome Bent 1 Insurance ER Patient c sdocplusS 010 dbfsserverspatient dbf Record 2 2 1 Enter the information in the Employer and Employed as fields as shown above in Figure 17 21 NOTE You are only required to enter employment information in this screen The remaining information will be filled in automatically when the Health Questionnaire HQ2 HQ3 form is scanned 2 Click Save then select the Forms tab at the top of your screen NOTE You are now in the Patient s Scanned Forms screen Your screen will appear EMPTY because you currently have no forms scanned for this patient Figure 18 below shows this screen with initial intake forms scanned for the selected patient Figure 18 Patient s Scanned Forms screen FA DocumentPlus 9 003B Database Maintenance DBMAN_B EXE WkSta SANDY Patient s Scanned Forms Jones Bob 3 Information 1 Information 2 Insurance 1 Insurance 2 Accident Notes Social Histor Exam Date Form Id Serial No Doctor Scan Date 61 67 2668 Date Order 61 67 2668 Ascending 61 67 2668 01 18 2088 C Descending Sort By Exam Date Print List Case Number Zi i Pick Hemove Doctor Insurance EN Main Menu Hom Paen Attorney 14 45 21 This screen lists all the forms that have been scanned for the selected patient The functions in this scree
2. Final Abbreviated Report Personal Physician Forms Active Signed By Form Current Personal V Initial D Final CE3 01 12 12 HQ3 01 12 12 RD2 01 12 12 Patient Letters Signed By Discipline Welcome To Practice Initial Your Doctor D C Initial Report Of Findings Current Your Doctor D C B CUSTOMIZING QUERIES Overview When you find that you are typing the same query entries for multiple patients you may want to consider customizing the queries This process saves data entry time by allowing you to either predefine entries into specific bubbles or create pick lists of multiple items to choose from 1 From the Main Menu of Document Plus click Utilities 2 Select Modify Predefines You are now in the PreDefs Select Form screen Figure 27 below 33 Figure 27 PreDefs Select Form screen FA Doc umentPlus 9 010A Modify PreDefs MODIFYPREDEFS EXE WkSta ServerActvy 58 Forms Report J gt 31 2 3 4 Bottom top Eri PreDefs Select Form Foms 1 1 4 Automobile Accident Questionnaire AA 0 Accident Injury Questionnaire AISS0 2 Clinical Evaluation CE Lll rd Select Cancel L HQ 3 Yd m We will now customize a bubble on the Health Questionnaire form HQ3 1 and click Select Select Health Questionnaire then double click on HQ 3 or highlight HQ 3 A
3. EAD 0 he The Past Have You Use Any Of The Following rth trol Pils es Corticosteroid ir e You Allergic To Any Medications o2 c5 st Medic atio 9 3 Click Add and type aspirin 4 Click Add and type codeine 5 Click Add and type penicillin 6 Click Add and type morphine 7 Highlight morphine and use the Move Item in List up arrow to arrange it alphabetically between codeine and penicillin 8 Click Close Save at the bottom of this screen NOTES a You may list up to 99 different items in each predefined bubble a You may Select the Always Use box for any predefined item When the associated bubble is bubbled on the form you will not have to enter a query regarding the item and it will always appear in your reports automatically Qv i Always Use c Click the Report Location button to print a list of all predefines entered for a particular d Click the Report button in the upper left corner of the Modify Predefs screen to list of all predefines for the selected form f TARZET entrar oul ERU SS eM SET IT C FT FT PPETT F ITTT 36 REPORTS Refer to the tables below to determine which forms are required for each report Summaries Automobile Accident Automobile Accident Questionnaire AA 0a Daily Notes Daily Notes DN 2a DN 3c DN 4 Roland Morris Acute Low Back Pain Dis
4. Man Adj Section Page 2 Bottom DN3c Form saa 1 2 S S oe w C Bie dite ike Pillows lt Support Orthotics Ice Pack F amp t Multivitamin 48 X RAYS The X Rays section is to be used as a billing tool for your x rays If this daily note is to be used in conjunction with a billing system and is filled out for the first visit you will mark all of the x rays taken This section can be used when you take additional x rays or re takes The x ray information will also appear in your daily notes There are items in this section that can be predefined 26 Locate X Rays on your form see Figure 10 below NOTE For this tutorial we will not bubble anything in the X Ray section Figure 10 X Rays Section Page 2 Lower Right DN3c Form Cerv A P Lat Thor A P Lat Lum A P Lat Lum Compl Cerv Dav Ser Cery Compl S View 14X17 S View 10X12 49 OBJECTIVE The information from this section makes up the OBJECTIVE portion in your daily note reports Leg Length Deficiency This section is used to document asymmetry Biomechanical Exam This is the section the doctor will use to document examination findings for that day s visit NOTE If RADIATE is bubbled TENDER must also be bubbled TENDER may be bubbled without RADIATE When Radiate is marked in the cervical thoracic or lumbar region an option exists to designate to what
5. and reflects the updated diagnoses If New Additional is bubbled on the DN3c form the new diagnosis codes will replace the old When a re evaluation is done the new codes take precedence and replace the previous codes from the DN3c form Dn Sbj Daily Note Subjective This section reflects the information bubbled in the Symptoms section on the previous daily note DN3c form BiNk P Sf Sr Bilateral Neck Pain Stiffness Soreness Indicates location and description of the problem 1 column Symptoms Section I i gt S Intensity Severe Indicates severity of the problem 2 column Symptoms Section I c gt Sp St Characteristics Sharp Shooting Indicates characteristics of the problem 3 column Symptoms Section I f gt F Frequency Frequent Indicates the frequency of the problem 4 column Symptoms Section I s gt U Status Unchanged Indicates whether the problem is improving or not 5 column Symptoms Section I X Ray This section contains X Ray information from the Radiographic form completed during the patient s initial visit 63 Note This section contains in office notes that have been either typed in under the Notes tab in the patient database or entered via the SOAPT 2 bubbles in the lower left corner of page on the DN3c form Plan The information in this section reflects the current
6. Guardian Signature Date Options in this screen allow you to Print Page Print the current page Print All Print all pages for the current document Next Page View the next page s in the current document Previous Page Return to the previous pages in the current document Change Document View a different document for the existing patient Zoom Enlarge the page currently visible on the screen Flip Rotate the current document 180 Exit Return to the Generate Documents screen Crop Width Crop Height Crop the page currently visible on the screen Append or Rescan a Record Follow the steps below to replace a record or add pages to an existing record From the Main Menu click Scan Images 2 Select a patient from the Pick Patient list Select the record you wish to replace or append from the list of available documents and click Scan 9 The Medical Record On File screen now appears Shown in Figure 9 below Figure 9 Medical Record On File screen FA DocumentPlus 9 010A Scan Images SCANIMAGE EXE WkSta ServerActy New Medical Record Patient Name Jones Bob ID 3 Medical Records On File CPI 2182701712 16 26 52 Medical Record On File Patient Name Jones Bob 0000 Idi 3 Record CPI Pgs 2 Scanned 020112 16 26 52 Append Ignore Enter New Medical Record Descr
7. RAM RtClmLtUTP RAM BiClm Heel To Shin HTS HTS Right Rt finding Left Lt finding Bilateral Bi finding finding Clumsily Clm Unable To Perform UTP HTS LtClm Deep Tendon Reflexes DTR DTR Biceps Bic finding Triceps Tri finding Brachioradialis Bra finding Patellar Pat finding Achilles Ach finding finding Right Rt 0111314 Left Lt 0111314 Bilateral Bi O111314 DTR Bic Rt0O Tn Lt4 Bra Rt3Lt4 Pat Bil Upper Extremity Motor Examination UExtMF UExtMF Shoulder Abduction ShrAb finding Wrist Extension WstEx finding 128 Wrist Flexion WstFIx finding Finger Extension FngEx finding Finger Flexion FngFIx finding Finger Abduction FngAb finding Finger Adduction FngAd finding finding Right Rt 011121314 Left Lt 011121314 Bilateral Bi 011121314 UExtMF ShrAbzRtO WstEx Ltl WstFlx Rt3Lt4 FngEx Bi0 Lower Extremity Motor Examination LExtMF LExtMF Hip Flexion HpFIx finding Leg Extension LgEx finding Foot Dorsi Flexion FtDFIx finding Great Toe Dorsi Flexion GTDFIx finding Foot Plantar flexion FtPFIx finding Great Toe Plantar flexion GTPFIx finding Foot Eversion FtEv finding finding Right Rt 011121314 Left Lt 011121314 Bilateral Bi 011121314 LExtMF HpFlx Rt0 LgEx Ltl FtDFlx Rt2Lt3 GTDFIx Rt0OLt4 Heek Walk HW Right Rt Left Lt Bilateral Bi HW RtHW Toe Walk TW Right Rt Left Lt Bilateral Bi TW BiTW Sens
8. 0 lp c Lock Letter Greeting Dr Your C Letter Signature Doctor Your D C a Insurance Signature Doctor Your D C a Address Phone Numbers Street 123 E Federal Hw Office 1 Suite la Office 2 City Fax State Zip Code Home E Mail doc aol com J Hain menu ED now Emm car Doctor c sdocplus3 010 dbfsserversdoctor dbf Record 1 1 i 10 52 18 5 Click Save then click the Pick Doctor button 13 NOTE You are returned to the Pick Doctor screen See Figure 5 below Figure 5 Pick Doctor screen Le F Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv 4 Pick Doctor e Clear Doctor s Name Id PM Ref gt Doctor D C Alpicioleteictalitsikiiiminfolelotrtsiriulwviwixity z f New X Main Menu ue Insurance r3 f Ckidno c docplusS 010 dbfsserversckidno dbf Record 4 5 We will now enter the information for Bob Jones Personal Physician This information can be found on the Health Questionnaire HQ3 Form Pg 3 question G1b 1 Click New See Figure 5 above NOTE You are in the Doctor Information screen Your screen will appear EMPTY In Figure 6 below the physician information has already been entered 2 Use the pull down menu to select Personal as the Type of doctor you are entering information for 3 Tab over to Title and enter the information f
9. Warnings HQ Dysfunction HQ 3 Complaints v Intensity v Frequency Status Nutritional Mode None 7 ia a Documents Header DOB Footer V Practice V Doctor s Name V Address Doctor Doctor Marked On Form Document Actions Layout Letter Layout Heport Save Cancel L f Pmsware c docplus3 010 sdbfpm pmsvare dbf Record EOF 11 Record Unlock TI Complete the following steps to customize the Miscellaneous 2 screen l Cover Letters Options for this feature are Policy and or Claim Items selected here will appear on cover letters for insurance and attorney reports Warnings HQ Dysfunction If selected the system will not give validation warnings when scanning the health questionnaire form It does not override validation errors those must be entered HQ 3 Complaints If Intensity Frequency or Status is selected a warning will appear upon scanning if nothing is marked in those areas Click Continue to bypass the warning or correct the form and re scan it This serves as a reminder in case you accidentally forgot to bubble something in those areas Nutritional Mode This section works with our Symptom Survey SS form Please call our tech support department at 800 642 0600 for assistance with setting this up Documents e Header If DOB is selected the patient s date of birth will appear in the header of your reports e Footer You may choose
10. a recently sprained 323 66 ankle that he recently pulled his lower back or that he recently hurt his neck New Additional New Additional is located under Assessment Diagnosis and is typically used in conjunction with the New Injury bubble in the previous section Some additional diagnosis codes are included in the program To add more codes to this list follow the eight steps on Pg 79 Type all entries into both the Text ID and Predefined Text boxes clicking Add between each entry Click Save Close when finished Example of text as it appears in the daily note report t is my opinion that the patient is additionally suffering from An example of what you might enter to complete the above statement is 22 4 Cerv Disc Degeneration Of Addt l Note This bubble is for entering additional notes regarding the progress or status of a patient When predefining this bubble you want to enter the text that will appear in your pick list into the Text ID box The text will appear in the report exactly as it is entered into the Predefined Text box and should be entered in the form of a complete sentence Examples of what you might enter for Of Addtl Note Text ID Predefined Text Resolved There is no further treatment needed for this condition Unchanged There is no change in the patient s condition at this time Improving The p
11. 37 In C2 bubble A anterior 38 In C3 bubble R right 39 In C7 bubble R and SUP right and superior NOTE Use of the Thrust Report section of the form is not required You have the option of solely using the Today s Tx General Listings section in the lower left corner of Pg 1 If the Thrust Report section is used it will be listed first in your daily note reports If only the Today s Tx General Listings section is used Tx1 will appear first 52 TODAY S Tx GENERAL LISTINGS The Today s Tx General Listings section is used to document the treatment rendered on each visit and appears as part of the TREATMENT portion in your daily notes report There are items in this section that can be predefined 40 Locate Today s Tx General Listings on your form See Figure 13 below Notice that in this section there is a Tx1 and a Tx2 section This feature enables documentation of two techniques in addition to what was recorded in the Thrust Report Page 52 In this section you also have columns in which you are able to document adjustments to the upper and lower extremities Each extremity column has a separate technique bar 41 Locate the technique bar in the Tx1 section shown in Figure 13 below 42 Bubble MM manual manipulation 43 Bubble 5 and 6 in the cervical area under Tx1 44 In t
12. in the section and the report will reflect that all ranges of motion in the lumbar spine are normal and the normal degrees will be listed If you find that all ranges of motion 106 are normal with the exception of one or two you can mark Normal In All Positions Except and choose the deficiencies found You may also just mark a particular range of motion tested and skip the rest The numbered bubbles in each of the ranges tested represent degrees and Tens may be combined with Units Though it is not required if you choose to mark the bubbles for additional descriptors associated with range of motion there can be only one choice of Dull Pain or Sharp Pain f you mark the bubbles for Spinal Level Of or Radiates To queries will appear These must be answered for the system to complete the report NOTE There is no Rotation of the lumbar spine e Compression Tests D3b Valsalva D3b1 Only one choice of Negative or Positive may be marked Both Left and Right may be marked Additional bubbles may be marked to indicate where pain was produced during the test If the Other bubble is marked it supersedes the rest and a query will appear Tliac Compression Test D3b2 Only one choice of Negative or Positive may be marked Both Left and Right may be marked Additional bubbles may be marked to indicate where pain w
13. 48 Treatment Codes When one of these Tx Codes is bubbled 98940 98941 98942 or 98943 the number of regions adjusted will be compared to the number of subluxations marked in the Biomechanical Exam portion of the Objective section on the daily note If you choose a code that does not compare a Validation WARNING will prompt you to make the necessary corrections to either the billing code or the number of spinal segments treated You have the option to click Continue past this warning so it will accept the code you have chosen If you are using this section for billing purposes you will want to bubble the appropriate treatment code in this section If you do not have an interfaced billing software you can simply leave this section blank if you choose The following is a chart of the Man Adj section requirements These codes compare the regions adjusted with the number of subluxations marked in the Objective section on the DN3c form 98940 Bubble 1 to 2 spinal regions in the Objective section 98941 Bubble 3 to 4 spinal regions subluxations 98942 Bubble all 5 spinal regions 98943 Bubble extremity only Case Numbers The 5 case number bubbles serve only to designate a different case number for an existing patient The default case number is 0 The first time you assign a case number to a patient using this section use case number 1 If you have a billing software that i
14. Check the grammar on these screens to insure that they are written in past tense 5 Click OK to advance through the queries 6 When you have finished your attorney narrative will generate automatically C GENERATING DOCUMENTS PATIENT LETTERS Patient Letters Overview Patient letters are excellent client retention and practice building tools Welcome to the Practice You may generate a welcome letter for new patients You can customize this letter to suit the specific needs of your practice Thank You A Thank You letter can be generated for referring patients You may generate a Thank You letter only if you have a referred from patient entered into the database 30 Initial Report of Findings Written in layman s terms this document is designed to educate the patient and encourage them to follow their long term care plan Generate an Initial Report of Findings 1 For this tutorial select Initial Report of Findings under Patient Letters 2 Click Generate Notice the simplicity of how the document is written 3 When you have finished reviewing the document close the window to exit the document D GENERATING DOCUMENTS CONTROLS Controls Overview This section enables you to navigate within Document Plus from the Generate Documents screen Generate Allows you to generate any available documents You may generate many d
15. Find what field type the word or phrase you want to replace In the Replace With field type in the text you want to appear Click Replace all and click OK in the replace notification box that appears Click Close in the Replace dialog box If you need further training or technical support please call 800 642 0600 or 770 814 2442 125 APPENDIX J Abbreviations The travel card section of the daily note contains abbreviations Most of these are standard in the industry and easy to understand This section outlines the syntax rules that define how the abbreviations are linked Travel Card Syntax Rules 1 Capital Letters Use for the first letter of each word that is part of an abbreviation Deep Tendon Reflexes Example DTR 2 Double Colon Indicates a section of the examination Neurological Assessment Example Neuro 3 Single Colon Identifies a group of tests Cervical Range of Motion Example Cerv ROM 4 Equal Sign Indicates that a test has multiple findings Cervical Compression Tests Flexion Example Cerv Cmp Flx 5 Comma Separates multiple tests of a group Thoracic Spinal Exam T1 Right Spasm amp T2 Right Tenderness Example Thor SpnEx Tl RtSp T2 RtTn 6 Semicolons Separates test groups and individual tests Cervical Compression Tests Flexion is Positive with Back Pain and Extension is Positive with Bilateral Leg Pain Range of Mot
16. Insurance Companies This feature enables you to generate a list of contact information for insurance companies listed in your database e New Patients This feature allows you to generate a list of new patients for a specific date range o The report will organize the above information by the doctor seen and the visit date e Patient Carrier This feature enables you to generate a list of insurance companies and the patients that are covered by them o This list is sorted alphabetically by insurance company and lists patients covered under each company e Patient Consultation This feature enables you to generate a list of consultation dates by patient e Patient List This feature enables you to generate detailed information for a specific patient o Information in this report includes Patient Name Address Phone Number date the patient entered the practice consultation date begin treatment date treatment phase primary and secondary insurance carrier e Referred From Clinicians This feature enables you to generate a list of clinicians who have referred patients to you e Referred To Clinicians This feature enables you to generate a list of clinicians you have referred patients to e Treatment Phases If you have further questions regarding the List features please contact the training department at 800 642 0600 116 APPENDIX G Utilities Functions
17. Kmp Rt BkP LtLgP Lt BkP BiLgP BiFbP Mnr Adm RtFIxAnL ROM FIx MoRs Ext SrRs P RtLatFlx P 2 Version from the Abbreviated Report Clinical Evaluation 09 03 97 Nuro CP R10 Lt Brt RiCar BiScl RRCFM CN IIT RAM RtClm LtUTP HTS BiClm DTR Bic Rt Tri bil UExtMF FngAb Rt3 FngAd Bi4 LExtMF GTDFlIx Rt4 RtHW BiTW SenDef CI ZRIHyo C2 RtHyp LtHyo Plt RtAbs LtUpg Cerv SpnEx C4 RtSp RtIn Mp C5 RtSp RtIn Mp Co RtSp RtIn Mp C7 RtSp RtIn Mp Cmp FIx NkP Ext BiUEP RtLatFIx NkP LtUEP LtLatFIx NkP BiUEP Val Dst ROM Flx MoRs Ext SrRs P Thor SpnEx T1 5iSp BiwMlTn AF Mp T2 BiSp BiM1Tn AF Mp T3 BiSp BiiMlTn AF Mp LS SpnEx L5 RtSp RAMITn Mp Sac RtSp RAMITn Mp SI RtSp RtTn RtMp SLR Rt BkP Q 40 Lt BkP LgP 60 RtBrg BiWLR Lnd Val Kmp Rt BkP LtLgP Lt BkP BiLgP BiPbP Mnr Adm RtFlxAnL ROM Flx MoRs Ext S7rRs P RtLatFlx P Section 2 Health Questionnaire Daily Note Complaints Complaints Cmplts Cmplts Location 1 complaints Location 2 complaints Location n complaints Note HQ 0 no right left for Head Neck Upper Back Mid Back and Low Back Locations Right Left Bilateral Head Rt Lt Bi Hd Right Left Bilateral Neck Rt Lt Bi I Nk Right Left Bilateral Upper Back Rt Lt Bi JUBk Right Left Bilateral Mid Back Rt Lt Bi MBk Right Left Bilateral Low Back Rt Lt Bi LBk Right Left Sh
18. NOTE The third column in Symptoms Section 1 reflects CHARACTERISTICS OF PAIN If you have anything bubbled in this column you MUST bubble Pain in the first column Not doing this will cause errors to appear when you scan the form Pain can be bubbled and stand alone without any further descriptors 40 Symptoms Section II In this section the patient indicates pain rating time of day symptoms are worse fills in the pain diagrams and indicates whether or not a new injury exists The patient then signs and dates the form in the space provided All of this appears in your daily note and should be filled out by the patient on each visit There are items in this section that can be user defined How would you rate your pain today This is your Visual Analog Scale The scale will reflect an overall pain rating from the patient s perspective If your symptoms change when are they worse In this section the patient can bubble any or all applicable times of day The Other bubble can be predefined for other circumstances that may aggravate a condition such as when bending when lifting or before getting out of bed Pain Diagrams In the Pain Diagram you may want to have the patient mark the area in which they are experiencing pain rate the pain intensity using a scale of 1 10 and even write in the percentage of the day they are experiencing that degree of pain in a particular
19. Posture Examination IE esee Observations e Body Type Choose one bubble e Presentation o Choose Erect or something else in the section but not both o Choose Left or Right o There can only be one choice for Slight Moderate or Severe e Ambulation o Choose either Normal With Assistance or Non Ambulatory You may only choose one 100 o There can only be one choice for Slight Moderate or Severe e General Choose either Left or Right for all items here For Winged Scapula both Left and Right may be marked e Cervical You may only mark one choice for Left or Right one choice for Anterior or Posterior and one choice for Flexion or Extension e Torso You may only mark one choice for Left or Right one choice for Anterior or Posterior and one choice for Flexion or Extension e Pelvis You may only mark one choice for Left or Right one choice for Anterior or Posterior and one choice for Flexion or Extension e Feet You may only mark one choice for Pronation or Supination one choice for Hyper Hypo or Pes Planus and only one choice for Foot Inversion or Eversion ad oen Leg Length Deficiency e Marking Legs Balanced supersedes any ot
20. S Initial Re Eval I Final Insurance Missing PRIMARY Insurance Co Patients Hecord Initial Re Eval I Final Doctors Casey Ben M D Main Menu Beferred From z C From Initial Re Eval l Final Query Ins iv Dates Admin Referred To C To Initial Re Eval I Final Personal Physicia Forms Active Personal v Initial Re Eval Final CE3 01 12 12 HQ3 01 12 12 SEEGUm RD2 01 12 12 Signed By Discipline Initial Your Doctor D C Current Your Doctor D C Towhom c docplus9 01 0 dbf misc towhom dbf Record 6 37 Exclusive NUM 12 25 16 NOTE See Page 37 for forms required to produce each document 21 A GENERATING DOCUMENTS REPORTS SUMMARIES Reports Overview With the exception of Daily Notes and HMO Forms the documents listed under Reports appear in a bulleted summary format and are intended for in office use Generate an Initial Patient History 1 To select the summaries you want to generate click on the name of the document s under Reports To de select the document click on the name again or click Clear under Controls 2 For this tutorial select Initial Patient History 3 Click Generate under Controls The system will now review the scanned forms for additional hand written information The Information Written on Form or
21. SOAPT 2 bubbles appear in your daily note reports and not in the travel card See Advanced Setup Pg 72 78 47 Locate SOAPT 1 amp 2 on your form See Figure 14 below These bubbles can be found in the lower left corner of page 1 on the DN3c form 48 Bubble A1 See Figure 14 below Figure 14 SOAPT Section Page 1 Lower Left DN3c Form 54 STEP 2 Scanning the Daily Note Form DN3c Provided that you entered Bob Jones into the patient database in the first tutorial you are ready to scan the daily note form that was filled out in Step 1 of this tutorial NOTE Once you click the Scan Forms icon on the Main Menu the Forms Scanned screen will y appear To generate your daily note report automatically each time a DN form is scanned select Generate Daily Note after Scanning Each DN Form in the lower left corner of this screen IF the Generate Daily Note After Scanning box is selected follow the steps listed below The Pick Insurance Company screen will appear SELECT the Primary or Secondary Insurance Company or click NONE Your DAILY NOTE REPORT will be generated automatically Close the report The Forms Scanned Exit Screen will appear Select EXIT or MAIN MENU to return to the main menu Dangers You may select whether you want to enter queries after you scan the form or when you generate the document Additional options a
22. Selecting this box will trigger a validation warning if New Injury is bubbled on a DN form upon scanning This is a reminder for you to update BOX 14 on the HICFA form 8 Pain Diagram Instructions If selected the following sentence will appear in the Subjective section of your daily note reports The patient was instructed to fill out the Pain Diagrams indicating each body area they experience pain He was also shown how to place a number that specifies the level of pain and percentage of the day that pain occurs The Effective date appears when the Pain Diagram Instructions option is first selected The above sentence will not automatically appear in daily note reports from forms scanned prior to the date shown Figure 3 Set up Consult Notes screen FA Document Plus Version 10 00 Miscellaneous MISC EXE WkSta ServerActv Setup Information Settings Daily Notes 1 Daily Notes 2 Consult Notes Miscellaneous 1 Miscellaneous 2 Consult CE O V Race M Demeanor V Posture V Head V Eyes V Thorax Note INS History Of Accident Pain Modifiers Attorney V Insurance Doctor OM V Dates Administered V NP RO Activities Malposition Articular v Subluxation Motor Functions All Normal Max 2 Date Of Accident Date of Accident Subluxation From CE 3 Malposition Query Document Actions Layout Letter Layout Heport Save Cancel Pmsware c docplusS 010 dbfspm pmsware dbf
23. State Zip Code Auto Pl Related Condition No Home Phone 813 596 4587 Fax Work Phone 813 589 6542 Birthdate 1070571952 SSN b55 55 5555 Age l Deceased Diver Lie E Ckidno c docplus9 010 dbfsserversckidno dbf Record 2 5 q 10 24 37 18 4 Click Save then select the Information 2 tab at the top of your screen NOTE You are now in the Patient Information 2 screen See Figure 14 below Figure 14 Patient Information 2 screen r FA Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv Patient Information lanes Bob 3 Information 1 Information 2 3 Insurance 1 Insurance 2 Accident Notes Social History Forms NOTE This screen Pimay Doctor Type C E enables you to link the Pick Doctor Your Doctor D C 001 ine Fm Cd In House doctor seeing Pick Refering Patien ds Pick Retenedto COLD the patient Primary Pick Personal Physiciam Casev Ben M D PER Pick Patient s Attorney Howe Harry Esq ATT Car e Physician and Dates Case Number JL Attorney to the selected Entered Practice First Consultation Last Visit Visits 0 Initial Exam Last Activity Visits Of Plan 0 Approved 0 patient If linked her C Last Re Exam Re ExamSchedued sds Visits Schedule Current Re Exam x Rays Scheduled Treatment Phase the informatio
24. The Utilities button is located on the menu bar at the bottom of the Main Menu This section outlines the available functions of the Utilities feature Follow the instructions below to access the Utilities menu 1 From the Main Menu click Utilities The Utility Functions menu will appear Shown below in Figure 1 Figure 1 Utility Functions screen F Document Plus 10 00 Document Plus Utility Functions f Miscellaneous Modify PreDefines Modify Patient f System Information Associated with Define Treatment Form f View Pulstar Data Codes Calibrate Travel Print Patient Labels f Verify Databases Cards E Print Medical Delete Form lal Records Functions of each item in the Utility Functions screen above are outlined below e Purge Patients Purge Patient criteria are set according to the number of days in the Inactive Patient Months field in the Miscellaneous 1 setup screen When utilizing this function 1f there are patients in your database that match the preset criteria they will be listed here and you will have the option to delete the patients on the list e Verify Databases This function enables you to scan all databases for system errors To run this function all other users must close the Document Plus program e Modify Patient Associated with Form In the case that you scan a form with the wrong
25. You will be entering information into the database scanning forms and generating documents Upon completion of this tutorial if you need further assistance please call our office at 800 642 0600 to schedule a training session To begin the tutorial it is necessary to complete a case study Download and print the Bob Jones Sample Case Transfer the information from the sample copies of the Health Questionnaire HQ3 Clinical Evaluation CE3 and Radiographic Examination RD2 onto actual bubble forms located in your starter kit using a NO 2 Pencil There are three steps to generating reports in DocumentPlus See Figure 1 below 1 Enter patient information into the database 2 Scan bubble forms 3 Generate the Documents Figure 1 Document Plus Main Menu b NN Step 2 hy Step 1 SE forms Enter patient Ta Document Plus 10 00 information ORSR S s Databases Scan Forms Office Reports Generate E T n Scan Images Generate Narratives documents Document Plus Version 10 00 WkSta ServerActy NUM 1 0 32 43 Z STEP 1 SETTING UP YOUR PRACTICE DEMOGRAPHICS This section of the tutorial will guide you through entering information into each of the four Document Plus databases Doctor Attorney Insurance and Patient A ENTERING INFORMATION INTO THE DOCTOR DATABASE 1 From the Main Menu click Databases See Figure 1 Pg 11 NOTE You are in the Pick Patient s
26. if you choose to mark the bubbles for additional descriptors associated with range of motion there can be only one choice of Dull Pain or Sharp Pain o If you mark the bubbles for Spinal Level Of or Radiates To queries will appear They must be answered for the system to complete the report 105 e Thoracic Torso Muscle Testing D2b o Both Left and Right may be marked o If you mark No Muscle Weakness Except you do not have to mark anything else in the section and the report will reflect that all thoracic torso muscle groups listed on the form were tested and were found to be grade 5 5 and intact If you find all are normal with the exception of one or two you can mark No Muscle Weakness Except bubble and select up to TWO abnormal findings For Reference 0 5ZNo muscle movement 1 5 Visible movement twitch but no movement at the Joint 2 5 Movement at the joint but not against gravity 3 5 Movement against gravity but no added resistance 4 5 Movement against gravity and resistance but less than normal 5 5 Normal strength e Mechanical Tests D2c o Chest Expansion Test D2c1 Only one choice of Negative or Positive may be marked A decrease in inches must be indicated o Sternal Compression Test D2c2 Only one choice of Negative or Positive may be marked A query will be generated for you to indicate the location of the pain
27. As Needed Per Day Week will indicate the frequency Weeks Months will indicate the duration of your treatment plan Only once choice may be marked for each For Example if you bubbled 3 for Week and 2 for Months the report will read The patient will be seen 3 times per week for 2 months PEDI oss Visits This Plan This section is for ASHP or HMO users There can be only one choice for Tens and Units 111 HS ases 4 H6 EET sees THIS aee H9 eoe H1 0 H11 H12 Work Status This section is used if you want the report to indicate what the patient s current status 1s as to being able to return to work or able to return to work with restrictions If you check anything under a other than Unable you must complete section b as well In this case the Other bubbles in section b do NOT supersede the other answers but are used to add additional restrictions or qualifications Home Duties Restrictions This section is used if you want the report to indicate any home duty restrictions The Other bubble does NOT supersede the other answers but is used to add additional restrictions or qualifications Rehabilitation for Home Use This section is used if you want the report to indicate any rehabilitation measures you want the patient to perform while at home Anything bubbled in this section will genera
28. Bilateral Bi WLR LtWLR Lindner Lnd Lnd Valsalva Val Val Kemp s Kmp Kmp Right Rt finding Left Lt finding finding Back Pain BKP Right Rt Left Lt Bilateral Bi Leg Pain LgP Kmp Rt BkP BiLgP Lt RtLgP Fabere Patrick FbP Right Rt Left Lt Bilateral Bi FbP LtFbP Minor s Mnr Mnr Adam s Adm Adm Antaigia AnL Right Rt Left Lt Flexion Flx AnL RtAnL LtFIxXAnL Range Of Motion ROM ROM Flexion Flx finding Extension Ext finding Right Lateral Flexion RtLatFIx finding Left Lateral Flexion LtLatFIx finding Right Rotation RERot finding Left Rotaton LtRot finding finding Mildly Restricted MiRs Moderately Restricted MoRs Severly Restricted SrRs Pain P ROM FIxzMoRs Ext SrRs P RtLatFlx P Examples 1 Version from the Travel Card Nuro CP RtO Ltl Brt RtCar BiScl RtCFM CN II III RAM RtClm LtUTP HTS BiClm DTR Bic Rt1 Tri Bil UExtMF FngAb Rt3 FngAd Bi4 LExtMF GTDFIx Rt4 RtHW BiTW SenDef C1 RtHyo C2 RtHyp LtHyo Plt RtAbs LtUpg Cerv SpnEx C4 RtSp RtTn Mp C5 RtSp RtIn Mp C6 RtSp RtTn Mp C7 RtSp RtTn Mp Cmp FIx NkP Ext BiUEP RtLatFlx NkP LtUEP LtLatFIx NkP BiUEP Val Dst ROM FIx MoRs Ext SrRs P Thor SpnEx T1 BiSp Bi MITn AF Mp T2 BiSp Bi MITn AF Mp T3 BiSp Bi MITn AF Mp LS SpnEx L5 RtSp Rt MITn Mp Sac RtSp Rt MITn Mp SI RtSp RtTn RtMp 131 SLR RtBkP 40 LtBkP LgP 060 RtBrg BIWLR Lnd Val
29. LAALLAAAAALLAL OOOCX CAZA Begin has NOT been marked Check Health Questionnaire pg 2 section is NOTE Validation WARNING You may Continue or fix and Re scan the form pcs 585850 G8 6 o CRm To Navigate the list Use PageUp har DERT Ow keys or the Mouse Jo Cancel this Scan Session Press the Escape key or click the Cancel button 25 C If you are getting a Validation ERROR Figure 23B below a Press any key to stop the beeping and read the screen Correct the errors on the form Click Re scan and scan the form s again REPEAT this process until you no longer see the Validation ERROR screen Figure 23B Validation ERROR r4 Document Plus Scan_VX SCAN FORMS Scanned Forms Validation ERROR Form Clinical Evaluation Id CE3a Sht 2 Serial 4 618572 aen eeeeie ia visit Date 01 12 2012 lt validation ERROR f Use the Vertical Scroll Bar Vrhen Cervical is marked Left Shoulder Depression Positive is required Check Clinical Evaluation pg 4 Orthopedic Exam Of The Spine section D1cd1 Cervical Spine Stretch Tests Shoulder Depression NOTE Validation ERROR You must fix and Re scan the form To Navigate the ist Use Pagellp key PageDown key Arrow keys or the Mouse fo Cancel this Scan Session Press the Escape key or click the Cancel button 3 Once scanning is complete press Ente
30. Narty c docplus8 010 dbfsdocs narrtv dbf Record 79478 171629 Record Unlocked NUM 10 53 52 6 Highlight an item in the Locate RD Image Files screen and click Find in the lower right corner of the screen to locate the desired image on your computer 119 A Locate Image File screen will appear Shown in Figure 2 below Figure 2 Locate Image File screen List view r Open Picture NOTE To view all images click on the view menu in the pulling hair out jpa Random HAT bmp Mv Recent Random HAT JPG Documents RD IMAGE 1 JPG 1 Bs mes 2 JPG upper right hand 3 RD IMAGE 3 JPGG corner and select Desktop PEIRA E aa thumbnails RLOV DT_Boubletree_Hotel_Denver_home_lefk jpg RLDOY DT_ Doubletree Hotel Denver heme right jpg G Sample Pictures it Scanner jpg amp dfeaeul jpg she881ex 71367 md ipg shei493ex 70349 md ipg shelz84ex 57822 md jpa sj m e a File name RD IMAGE 14PG v ox wt hy Documents hu Computer 7 To view images click on the view menu in the upper right corner of the Locate Image File screen and select thumbnails Shown in Figure 2 above The previously listed images will now appear as thumbnail sized images Shown in Figure 3 below Figure 3 Locate Image File screen Thumbnail view r Open Picture Look in A My Pictures perry to
31. To indicate where the cervical pain on the right side is radiating to locate the right upper extremity area U Ext on your form Bubble Tender and Inflammation 30 Under Posture bubble R Head Tilt 31 Under Forward Flexion bubble Cervical 32 In the Range of Motion section in the Cervical area bubble Decreased and Severe 50 Figure 11 Objective Section Page 1 Upper Left DN3c Form Some Assessment Leg Length Deficiency Equal rar usn e ugh e Biomechanical Exam i x 1 DES X a a oS S 4 X ww AM Ef CA cM zG XU a eb af ad Y i Posture 7R Forward Flexion Heod Til oco High Shoulder Lumbar High Hip Pain ES E CP e o_O Me Ar Cs i Da OP Range Of Motion eee ua Cervical o cow Dorsolumbar Antalgia ol THRUST REPORT Located on the right side of Page 1 is an area called the Thrust Report This section is used to document the primary adjustment technique by listing Adjustments documented in this section will appear as part of the TREATMENT portion in your daily note reports There are items in this section that can be predefined 33 Locate the Thrust Report on your form see Figure 12 below 34 Locate the technique bar slightly to the left of the TMJ box shown in Figure 12 below 35 Bubble Inst instrument 36 In Occiput bubble POS in the top right corner right posterior
32. and confirm that you are able to open the program Install Document Plus Install USB hub BEFORE installing the scanner be certain that the USB hub included in your initial shipment is installed This will prevent hardware problems from occurring ee m a 6 Install scanner Installation Call our technical support department at 800 642 0600 to install the Document Plus system If you have one of the Practice Management programs listed below ask the tech support representative to configure the interface Current Interfaces with Practice Management Systems ACS 800 375 2271 Price Free AMS 800 440 6949 Price Free DB Consultants 610 847 5065 Price Free EZ Bis 800 445 7816 Price 295 Genius Solutions 586 751 9080 Price 295 Eclipse 800 966 1462 Price Free Formsmith Systems Inc 770 478 2191 Price Free Herfert 586 776 2880 Price Free Inphase 800 490 3780 Price Free Sunrise Systems and Solutions 330 386 9300 Price Free TGI Autumn8 800 645 4309 Price 299 Nutritional Interface Partners Symptom Survey Maestro 585 924 4456 Computerized Fixation Imaging Pulstar 800 628 9416 Visit www docplus net for more information regarding Practice Management partners Ordering Forms Included with your initial purchase are 250 daily note forms and 25 each of all other available forms This will help you decide which forms your office will use To insure that you always have an adequate stock of form
33. and date or any combination of the three onto the travel card Scanned This feature allows you to choose the way patients appear in the Print Travel Cards screen Options are All all patients New new patients and Pending patients that have forms scanned but have not yet had a travel card printed for the most recent visit Figure 17 Print Travel Cards screen FA Document Plus Version 10 00 Miscellaneous MISC 2 423 WkSta ServerActvy Print Travel Cards MPatient Name 1 1 1 11 ase ER ones Bob 1715 26012 3 Fnd A Clear Mark On Form Query Edit iv Doctor it Form Print On Form DN3c v v Patient it Scanned Pending Davel pet Main M i ard All 4 ee Order Name v Setup Paticase c docplus3 010 dbP serverspaticase dbf Record EOF 2 Record Unlock NUM 15 04 51 2 You should see an asterisk to the left of Bob Jones name This means he is selected to have a travel card printed 3 Load a BLANK daily note form DN3c into your printer as if the upper left corner of Pg 1 were the logo on a sheet of letterhead 4 Click Print The next screen will give you the appropriate number of daily note forms to load In this case it should specify 1 form Click Print again 6 Remove the travel card from the printer You should see information printed in the upper left corner of Pg
34. area on the next visit selecting these will give you an error By default all are selected Section Marked Warning days Allows you to choose how many days you want to go back on a previous daily note before it will NOT give you an error for sections not marked 9894x Missing Warning If this is selected you will get an error if you have something marked in the objective section and did not bubble in one of the 9894x codes on the other side of the form If you have Subluxation from Thrust selected in the setup screen and you marked something on the thrust areas of the form you will also get this error if nothing is marked in 9894x codes Affects Condition Visits and Days fields will pull query information from the HQ2 or HQ3 form section B numbers 5 and 6 regarding what affects their condition If there is a 3 in the Days field you will be prompted every three days to select what affects the patient s condition The text will be added to the Subjective section of the daily note report after the pain scale information 74 5 CBP Traction Weight C2W amp CLT When this box is selected and a DN4 form is scanned a query appears to allow you to insert traction weight This will appear in your daily note report 6 Re Scan Query Edit If selected queries will appear every time you scan re scan a daily note form even when Always Use is selected for a particular item 7 New Injury Warning HICFA Box 14
35. both this choice and Unable to Perform which indicates a positive finding for the test C9 Toe Walk Able to Perform Negative and normal You may not mark both this choice and Unable to Perform which indicates a positive finding for the test CIO sisii Plantar Response e You may mark both Left and Right e Plantar Flexion Normal cannot be marked with any other option CI Ves Hoffman s Sign e You may mark both Left and Right e Only one choice may be marked for Negative or Positive but not both SCI sos Dynamometer e Both Left and Right may be marked but only one choice for Hundreds H Tens T or Units U may be marked per side e You may choose to bubble one Attempt or all three e The system will average together your findings and the report will list each individual attempt and give an average or the findings for the attempts EO ues Of Additional Note You can enter information for these nine bubbles each time you want to add additional information or you can predefine lists of customized entries to choose from SECTION D Orthopedic Exam of the Spine DI ese Cervical Spine e Range of Motion D1a o If you mark the Normal In All Positions Except bubble you do not have to mark anything else in the section The report will reflect that all ranges of motion in the cervic
36. can be only one choice for degrees at which pain was produced 0 30 35 70 70 90 If the Other bubble is marked it supersedes all other options and a query will be generated o Milgram s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked o Ely s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked o Nachlas Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test e Other 1 D3e Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text 109 e Other 2 D3f Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text e Other 3 D3g Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text e Of Additional Note D3h You can enter information for these thirteen bubbles each time you want to add additional information or you can predefine lists of customized entries to choose from The spinal examination section is essentially broken down into
37. dates in either Ascending last visit date on top or Descending 4 DN 3 Query If Document is selected query screens will appear when generating a report If Scan is selected query screens will appear while scanning forms 5 Subluxation from Thrust If this is selected the number of regions bubbled in the thrust report section on the daily note form will be compared to the objective section and will state subluxation in those areas whether you have marked subluxation on the form or not 6 Segment Grp This determines how consecutive segments will be presented in your reports Using the default setting of 5 as an example if segments C1 C2 C3 C4 C5 C6 and C7 are bubbled on the daily note form your report will read segments C1 C2 and C3 through C7 Notice that the last 5 segments were grouped together instead of being listed individually and separated with commas 72 7 Heading Attending Clinician This heading is what shows up in reports when Attended is checked either in this screen or in the Daily Notes Select Visits screen You might consider changing this to Attending Provider if you have physical therapists and or other practitioners that will be sending out daily notes 8 Symptoms Status Unchanged If selected the text in your daily note will appear as unchanged when using the same as bubble 1 e If you bubble worsening and on
38. doctors By selecting the information here you will not have to 73 select them in the Daily Notes Select Visits screen This will be for all patients Default is None so you can choose different formats for different patients 19 Region Adjustment and Adjustment Text This allows you to customize adjustment types on the four visit daily note form DN2 20 After completing the steps above click on the Daily Notes 2 tab See Fig 2 below to continue the set up process Figure 2 Set up Daily Notes 2 screen F4 Document Plus Version 10 00 Miscellaneous MISC EXE WkSta ServerActv Setup Information Settings Daily Notes 1 Daily Notes 2 Consult Notes Miscellaneous 1 Miscellaneous 2 Section Not Marked Warnings W Objective Adjustments CBP Exam V CBP Tx V Symptoms WV Diagnosis V Progress iv Plan V Modalities IV Rehab Therapy Section Marked Warning 60 Days iv 9894x Missing Warning Affects Condition 0 Visits 0 H Days M CBP Traction Weight C2W amp CLT Re Scan Query Edit New Injury Warning HICFA Box 14 Document Actions Layout Letter Layout Report Save Cancel Pmsware c docplus3 01 O dbf pm pmsware dbf Record EOF 11 Record Unlock Complete the following steps to customize the Daily Notes 2 screen l Section Not Marked Warnings If you mark something in a particular area of the form on a previous visit and did not mark the same
39. existing document to scan additional pages for Highlight the document in the Medical Records on File section and scan the additional page s e Create a new document Click New Document to create a new document listing for the current patient e Create a New Medical Record for a different patient Click New Patient to choose a different patient to scan records for from your patient database e Exit Clicking Exit will return you to the Main Menu Ignore Clicking Ignore dismisses the previously scanned document without saving and returns you to the Scan Document Images screen Options in this screen are listed above See Save Flip This feature allows you to rotate the current document 180 Change Patient Clicking Change Patient will take you back to the Pick Patient screen where you can select another patient to scan images for Change Document By clicking Change Document you can either select an existing document to add pages to or create a new document record for the current patient Exit Clicking Exit in this screen will return you to the Main Menu 89 and Edit Images when not in Scan mode To locate images and records that you have previously scanned 1 From the Main Menu click Generate Documents 2 Select the patient from the Pick Patient screen If there are no forms scanned
40. for the selected patient you may access scanned images and records by clicking Utilities on the main menu clicking Print Medical Records and choosing the desired patient You are now in the Generate Documents screen See Figure 6 below Figure 6 Generate Documents screen FA Doc umentPlus 9 010A Document Generation DOCUMENT EXE WkSta ServerActv PEE Generate Documents Jones Bob 3 Reports Consultation Note Controls Initial Patient History Attorney Howe Harry Esq Generate Clinical Evaluation Initial Re Eval Final Clear X Ray Summary Report i WIG eR atin Ge Insurance All Cities PRIMARY i Act ident Injury Hi story Initial jn He f val E Final Patients In Automobile Act ident T Dally Notes Doctors Main Menu Referred From s Outcome Measures From j Initial l Re Eval Final Query Edit iv Dates Admin HMO Forms Referred To C To I Initial Re Eval Final Abbreviated Report Personal Physician Forms Active Signed By Form Current C Personal Initial Re Eval Final CE3 01 12 12 HQ3 01 12 12 DEAE RD2 01 12 12 Patient Letters Signed By Discipline fons 01 15 12 Welcome To Practice Initial Your Doctor D C I Initial Report Of Findings Current Your Doctor D C 3 Click Records under the Controls heading You are now in the P
41. indicates 100 improvement and refers to the patient s condition at the time of the initial visit The previous responses to treatment will appear in the TxResp section of the travel card for easy reference Figure 5 Assessment Section Progress Page 2 right DN3c Form Resolved Unchanged Improving Worsening Of Addt Note Response A voro cm x lity HN o 13 Skip t To Tx Reduced Tenderness i ncreased Activities of Dally Living initial Visit and there IS no in 0 Reduced Inflammation x 43 PLAN This section makes up the PLAN section of your daily note report and references the most recently documented care plan whether it is from a Clinical Evaluation Re Evaluation or the Plan section on the daily note form If you do not bubble anything here you will NOT have a plan section in your daily notes There are items in this section that can be predefined See Customizing the Daily Note DN3c form on pages 79 84 14 Locate Plan on your form see Figure 6 below Per Initial Prev Plan Mark this bubble once you have established a treatment plan and want to refer to the previous plan in your daily note reports or in the Plan section of the travel card Changed As follows When bubbled the Information Hand Written on Form screen will appear allowing for the doctor s notes to be typed in You may use this bubble by itself or in addition to Per Initial P
42. intact However if you find all are normal with the exception of one or two you can also mark the No Muscle Weakness Except bubble and select up to TWO abnormal functions For Reference 0 5ZNo muscle movement 1 5 Visible movement twitch but no movement at the Joint 2 5 Movement at the joint but not against gravity 3 52Movement against gravity but no added resistance 4 5 Movement against gravity and resistance but less than normal 5 5 Normal strength Mensuration Mark only one choice per line for Tens and Units 102 al er Dermatomal Sensory Testing e This part of the test is divided into four separate sections corresponding to Cervical Thoracic Lumbar and Sacral dermatomes e You may use as many sections as needed or none at all e In any of the four sections you have the option of marking the No Sensory Deficit Except bubble and do not have to mark anything else in the section The report will reflect that all dermatomes listed in that particular section normal and intact However if you find that all dermatomes are normal with the exception of one or two you can mark the No Sensory Deficit Except bubble and choose the deficiencies found e Both Left and Right may be marked for a given Dermatome but both Hypo and Hyper may not be marked for the same Dermatome on the same side C8 ores Heel Walk Able to Perform Negative and normal You may not mark
43. is present together with spastic inflamed and tender deep paraspimal musculature ervical spine and supportmg structures therapeutic strengthening and in the nght lower cervical range which radiates Assessment of the patient s cime confimns a nght lateral flexion of the head to the thorax He stood with antenor translation m the cervical spine Cervical ranges ofmotion are decreased with severe pain confomnmg with clhmical evaluation ASSESSMENT Thereis no change in the prelimunary assessment PLAN His appointment frequency is detemnined to be three sessions per week for twelve visits His home care recommendations are changed to rest and ice This session a multivitamm was prescribed Doctor Your D C 23 E Federal Hwy Suite 1a Pompano Beach FL 33062 octor Your D C 123 E Federal Hwy Suite 1a Pompano Beach FL 33062 Pg 2 57 Summary Patient Visit 1 In this part of the Daily Note Travel Card tutorial you should have completed the following three steps Next you will print a Travel Card for Bob Jones second visit STEP 1 Complete the blank Daily Note form STEP 2 Scan the Daily Note form STEP 3 Generate the Daily Note Report As needed 58 Before Printing the Travel Card For training purposes some of the bubbles you marked on the form in the first part of this tutorial will need to be customized before you print the travel card for Bob Jones
44. ney No Attorneys On Filet Alpicioleteletalitsikiciminfolelotrtsiriuliwviwixty z Patient HD Main Menu mem Insurance Ckidno c docplus8 010 dbfssereersckidno dbf Record 4 5 We will now enter the information for Bob Jones Attorney 1 Click New to enter a new attorney NOTE You are now in the Attorney Information screen Your screen will appear EMPTY In Figure 9 below the attorney information has already been entered 2 Tab over to Title and enter the information as shown below in Figure 9 Figure 9 Attorney Information screen r FA Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv Attorney Information Mr Harry Howe Esq ATT Information 1 Information 2 Name Title First name Middle Last name Credentials Lock Letter Greeting E Fa ei Attention i Address Phone Numbers Street 5465 State St Office1 813 445 6598 Office2 Cy 1 City 23565 Fax 813 445 3519 State Zip Code Home Ckidno c docplus9 010 dbfsserveersckidno dbf Record 4 6 3 Click Save then click the Insurance button see Figure 9 above 16 C ENTERING INFORMATION INTO THE INSURANCE DATABASE NOTE You are now in the Pick Insurance Company screen See Figure 10 below Figure 10 Pick Insurance Company screen E n NOTE American Specialty Health Plans ASHP is pre programmed into your
45. not proofed will be added to the end of the document If Insurance is selected the doctor s signature will be added to the last page of the insurance report 7 Malposition Articular If selected the word subluxation will be included in reports when using the Clinical Evaluation 3 CE3 form 8 Motor Functions All Normal Max By default in the Neurological Assessment section on the Clinical Evaluation CE3 form you are allowed two exceptions if you bubble normal in all positions This feature allows you to select as many exceptions as you like 9 Date of Accident This allows you to choose heading abbreviation for date of accident 1 e D A DOA or Date of Accident 10 ASHP Subluxation From If Query is selected the subluxation part of the ASHP document will generate a query If CEZ3 Malposition is selected the subluxation information is imported automatically from the Clinical Evaluation CE form Malposition section Figure 4 Set up Miscellaneous 1 screen F Document Plus Version 10 00 Miscellaneous MISC EXE WkSta ServerActv Setup Information Settings Daily Notes 1 Daily Notes 2 Consult Notes Type Of Practice Patient Months Limited Discipline 1 Sid nthe Discipline 2 ges Purge Log Days Backup Days Discipline 3 Last DP Backup Install Mode ACTIVE Work Station Server Path CCXDOCPLUSS 010XDBFXSERVER Not Shared iv Report Em
46. o Well Leg Raise Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked 108 Additional bubbles may be marked to indicate where pain was produced during the test There can be only one choice for degrees at which pain was produced 0 30 35 70 70 90 If the Other bubble is marked it supersedes all other options and a query will be generated o Fajersztajn s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test There can be only one choice for degrees at which pain was produced 0 30 35 70 70 90 If the Other bubble is marked it supersedes all other options and a query will be generated o Kernig s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test There can be only one choice for degrees at which pain was produced 0 30 35 70 70 90 If the Other bubble is marked it supersedes all other options and a query will be generated o Sitting Leg Raise Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test There
47. of motion measurement s etc Documented on our DN FORM in the objective section under RANGE OF MOTION Figure 7 Objective section Range of Motion OBJECTIVE Some Assessment Leg Length Deficiency Fauci High Hip range Of Motion Cervical DorsoLumboar Dorsolumbar 96 Figure 8 Objective section Daily Note report Sample Text OBJECTIVE Cervical ranges of motion are diminished with severe pain corresponding with clinical evaluation Changes in the characteristics of contiguous and associated soft tissues including skin fascia muscle and ligament may be identified through one or more of the following procedures observation palpation use of instrumentation tests of length and strength etc Documented on our DN FORM in the objective section under BIOMECHANICAL EXAM using the SPASM and INFLAMMATION columns Figure 9 Objective section Biomechanical Exam Figure 10 Objective section Daily Note report Sample Text OBJECTIVE During the palpatory evaluation of the cervical spine spastic deep paraspinal musculatures are present overlying the left upper range There is spasm and edema noted specific to the right upper cervical spine Spastic deep paraspinal musculatures are detected at the left middle cervical area Myospasm and inflammation are located in the right middle cervical range Myospasm is apparent at the left lower cervical area Spastic and
48. patient number bubbled this function allows you to assign the form to the correct patient e Delete Form This function enables you to delete a specific form from a patient s database Once a form is deleted it cannot be rescanned 117 Modify Predefines This function opens the Predefs Select From screen through which you are able to access customize and modify the user defined bubbles on various forms For additional information see Customizing Queries Pages 33 36 Print Travel Cards This button opens the Print Travel Cards screen Here you may select patients for whom you wish to print travel cards for Calibrate Travel Cards This function enables you to adjust travel card alignment select a default printer for printing travel cards and set pre print preferences for doctor number patient number and date Export Patient Charges If in the Settings screen your system is set to export charges to your interfaced billing software manually you will need to use this function to transfer the charges If you do not have interfaced billing software this button will appear gray in color and will not be available for use The option is also available to manually export charges using a date range Define Treatment Codes This function allows you to pre set the billing codes for various items on the daily note form DN3 DN4 that will be transferred from
49. reduce pain and inflammation Example of text as it appears in the daily note report To reduce muscle spasm and inflammation electrical muscle stimulation is given to the upper cervical area for ten minutes Changed as Follows Use this bubble when you want to make adjustments to the current treatment plan You may use this bubble by itself to change the treatment plan or in addition to Per Initial Prev Plan to modify the current treatment plan When predefining in this section what is entered in the Text ID box is what will be visible as available predefines What is entered in the Predefined Text box will appear once a particular item has been selected The information will appear in your daily note report Examples are outlined below Example of text as it appears in the daily note report The current treatment approach changes as follows 7 Examples of what you might enter to complete the above statement Patient to receive massage 2x per week in addition to current treatment Patient to discontinue use of moist heat for home care Other Additional Recommendations This bubble can be used for any Other additional recommendations When predefining in this section what is entered in the Text ID box is what will be visible as available predefines What is entered in the Predefined Text box will appear once a particular item has been selected The informati
50. skipped until the next time you generate the document NOTE This will appear as a skipped query in your document Click Clear if you have entered something in error and want to make changes while you are still in the Information Written on Form screen Click Restore and the cleared information will be restored NOTE When an EMPTY button replaces the OK button you have the option of NOT entering questions that are not pertinent to generating a narrative If you select EMPTY that query will not appear in your document 4 To change a previously entered query Click in the Query Edit box in the Generate Documents screen See Fig 26 below All queries will be presented again Click OK or Empty until you see the one you wish to change Edit the query and click OK If you do not need to make any more changes click OK Skip Rest Figure 26 Generate Documents Query Edit x DocumentPlus 9 010A Document Generation DOCUMENT EXE WkSta ServerActy Generate Documents Jones Bob 3 Reports Consultation Note Controls Initial Patient History Attorney Howe Harry Esq Generate Clinical Evaluation Initial Final Clear X Ray Summary Report Forms Insurance T Patients Initial pa Final Doctors Casey Ben M D Main Menu Referred From C From Initial B Final HMO Forms Referred To C To Initial
51. software Ed Doctor FT k C Hain Menu uem Patient Record 1 1 Winsur co c docplusS 010 dbfssereersinsur co dbf We will now enter the information for a new Insurance Company l Click New to enter a new insurance company NOTE You are in the Insurance Company Information screen Your screen will appear EMPTY In Figure 11 below the insurance information has already been entered 2 Tab over to Company Name and enter the information as shown below in Figure 11 Figure 11 Insurance Company Information screen r FA DocumentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv lt Insurance Company Information Type Names 7 c P NOTE It you do not have Type Insurance Ph Reference si Medicare Format NOTE If Medicare ompany Name 99 1 a practice management iecit Format is selected software that interfaces PME Ua Der z reports and narratives i HMO with Document Plus the associated with this Address Phone Numbers e PM reference field Steet 408 State Street Main insurance company will a 2 Cd ff Contes along with Phone Ciy Fa 770 318 5437 have the patient s date Numbers are for in a of birth and Medicare house use and do not ID at the top of the appear in any reports page and the doctor s oe signature at the bottom Attorney Rinsur co c SsdocplusS 01
52. two sections with Edema Spasm and Tenderness grouped together as to how they are reported and Trigger Points Articular Fixation and Malposition grouped together in their reporting In the systems set up menu you can choose to have the group that includes Edema Spasm and Tenderness reported by individual levels that you mark For example Edema at the C1 and C3 levels or you can set the system to report by region U Upper M Middle L Lower for example if you mark same as the previous C1 and C3 the report will state that Edema was found overlying the upper and middle cervical regions You may choose L Left M Middle or R Right for any given level Additionally Tenderness has bubbles labeled 1 4 that you may choose to further indicate the Grade of tenderness elicited during the exam For example a Grade 4 Worst tenderness The sections that report Trigger Points Articular Fixation and Malposition cannot be grouped by upper middle or lower region and will be reported by the specific spinal level indicated Additionally by default if Articular Fixation or Malposition is checked the report will say just that without the word Subluxation added However if you would like the system to use the term go to set up menu and look under spinal examination for the CE3 and check the box that indicates adding the term Subluxation to the report For example without the box checked the report will s
53. under the Ice column shown below in Figure 7 19 Drop down to the time increments in the Ice column and bubble 15 min 20 Draw a heavy line down through the upper middle and lower cervical area under the Other 3 column 21 Drop down to the time increments in the Other 3 column and bubble 10 min We will predefine this bubble with another modality prior to scanning the form H mci CH M M M M M 17 y ie oe O6 6 e d Gi cv 45 REHAB THERAPY The information from this section appears as part of the TREATMENT portion in your daily note report This entire section 1s user defined If you do not predefine the therapies a query screen will appear when you scan the form and you must enter the information each time 22 Locate Rehab Therapy on your form see Figure 8 below 23 Bubble 10 in the cervical column as shown in Figure 8 below Figure 8 Rehab Section EE 2 Bottom DN3c Form Rehab Therap USER DEFINED Same Tx E e as PP o Or KERR NNN Dap ab dp dp d aD gp a 3n GP 33 46 MAN ADJ Manipulations Adjustments This section is used primarily for billing purposes The information with the exception of the treatment codes and the case numbers will appear as part of the PLAN section in your daily note report There are items in this section that can be predefined 24 Locate Man Adj on your form see Figure 9 Pg
54. word document is up on the screen select File then Save or click the disk icon on the toolbar 2 Patient folders have been created to separate patient reports The reports are stored in folders according to the first letter of the patient s last name Each patient has a personal folder within the letter folder 3 When you need to retrieve a specific document it can be accessed in Microsoft Word by clicking File Open Microsoft Word can be accessed from the Main Menu of DocumentPlus by clicking on the MS Word button on the lower left hand corner of your screen It is highly recommended that you always make changes to documents in the query screens in Document Plus and NOT by editing directly in Microsoft Word Once the document is generated if you need to make changes to the blue text you should always return to the Generate Documents screen click to select the Query Edit box on the right and Generate the document again All query screens will re appear Click OK or Empty until the one you want to edit appears Microsoft Word Find and Replace Follow these instructions to automatically replace words or phrases in any document with words or phrases you specify E a uio 6 Generate or open the document that contains the words you want to replace On the menu bar click Edit then Replace You should see a small dialog box labeled Find And Replace In the Replace dialog box
55. 0 dbfsserversinsur co dbf Record 2 2 3 Click Save then click the Patient button 17 NOTE You are in the Pick Patient screen See Figure 12 below Figure 12 Pick Patient screen r FA Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv d Pick Patient J t 05 ed a Pickpati c docplusS 010 dbfsserverspickpati dbf Record EOF 1 Record Unlock We will now enter the information for a new Patient The Bob Jones new patient information can be found on the Confidential Patient Information sheet that was completed for this training 1 Click New to enter a new patient NOTE You are in the Patient Information 1 screen Your screen will appear EMPTY In Figure 13 below the patient information has already been entered 2 Enter a DocPlus Number 3 for Bob Jones 3 Tab over to Title and enter the information for Mr Bob Jones as shown below in Figure 13 Figure 13 Patient Information 1 screen r FA DocumentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv Patient Information 1 Jones Bob 3 Information 1 MW nformation 2 Insurance 1 Insurance 2 Accident Notes Social History Forms DocPlus Number 0000000003 Name Tile Mr Fis Bob__ Mid Last Jones O O Z Oo o o Letter Greeting Mr Jones E Street 123 Main Street Mele F pne ae City 35648 Employment Related Condition
56. 1 7 Check the alignment of the doctor and patient numbers The 1 should be bubbled under DR and the 3 should be bubbled under Patient Number If the pre printed black squares do not line up you will need to adjust the calibration settings before going any further Please contact our technical support department at 800 642 0600 for assistance a By default ALL patients in the current list are selected as indicated by an asterisk to the left of the patient name This means the daily note is active and a travel card will print b Patients can be selected or de selected by double clicking on the name or by highlighting the name and clicking select at the bottom of the screen c To save time consider printing all travel cards for the day either first thing in the morning or the day before Customizing Travel Card Setup You may want to change the default settings for the way your Print Travel Cards screen appears 1 Click on Travel Card Setup in the lower right corner of the Print Travel Cards screen The Travel Card Default screen will appear Figure 18 below Figure 18 Print Travel Cards screen Travel Card Default Sele Options iv Mark Doctor Number iv Mark Patient Number Mark Date i Set Pending Automatically i Mew Patients Change defaults for items that will pre print onto the form and for the way your patient list is sorted in the Print Travel Card
57. 724 6 736 81 738 4 755 30 781 9 846 1 726 1 726 31 726 32 840 0 841 0 844 0 845 0 LS Spondylosis LS Disc Disp Hern LS Disc Degen LS Stenosis LS Pain LS Sciatica LS Root Comp LS Facet Syn LS Myofascitis LS Seg Dysf Sublux LS Congenital Anom LS Asymmet Facets LS Sprain Strain Hip Osteoarthrosis Sacroiliac Syn Limb Shrtng Acq Pel Spndlsths Acq Limb Shrtng Cong Pel Abnorm Posture Sacroiliac Sprain Rotator Cuf Shld Syn Med Epicon Elbow Lat Epicon Elbow Shld Sprain Strain Elbow Sprain Strain Knee Sprain Strain Ankle Sprain Strain Patellofemoral Dysf Syn Syndrome Cerv Other 1 Cerv Other 2 Thor Other 1 Thor Other 2 LS Other 1 LS Other 2 Pel Other Perp Jnts Other 1 Perp Jnts Other 2 Lumbar Spondylosis Lumbar Disc Displacement Herniation Lumbar Disc Degeneration Lumbar Stenosis Lumbar Pain Lumbar Sciatica Lumbar Root Compression Lumbar Facet Syndrome Lumbar Myofascitis Lumbar Segmental Dysfunction Subluxation Lumbar Congenital Anomaly Lumbar Asymmetrical Facets Lumbar Sprain Strain Pelvic Osteoarthrosis Of Hip Pelvic Sacroiliac Syndrome Pelvic Limb Shortening Acquired Pelvic Spondylolisthesis Acquired Pelvic Limb Shortening Congenital Pelvic Abnormal Posture Pelvic Sacroiliac Sprain Peripheral Joints Rotator Cuff Shoulder Syndrome Peripheral Joints Medial Epicondylitis Elbow Peripheral Joints Lateral Epicondylitis Elbow Peripheral Joints Shoulder Sprain Strain Pe
58. BR Scan Image CPI Pe 1 Jones Bob 3 CONFIDENTIAL PATIENT INFORMATION cave or merit T od acr aa E ranae E 30032 ero id E Ignore Flip _Botresh_ Refresh Change AN TO BHT ACT OA D ee OO cTHER TO Patient reo oa GH GPR Ue ce C eee C Ch MWe DODAY Ns CAEHLI cape O wee wsTERCAMOL ae cece OD one DO EE Document k Hain Menu 55M SAME AS AEE Ie nan pep Ol Ce hies Ine ino Shade ea ore dada AR coc Dee PUOMEWD i ONEA HIA As Lon mE RORUTGI TA Di Laur Ry PX dici RR Gand pigri i oigo bung ie bi ru paul im inn B piriy nei mimpin snae RR Sg DEMNM VIALE ER Erde Re Marii iiri Wei im lin e im pie sser ree cg d p Rote Tire Ph RECO a y ina utem nae uem Pun eee bp rep cry mui of emt V by ei pim Rad Dy p cua EAM RANA d BAP EEDA Ma Rae Gud gs Ny de Rei eee eee be i a ri et Led AMO RAEE D DN a rre p ERAR dead AN pe sia eh did panakis nee ue CRAT iniri us 88 Using the toolbar at the right of the Scan Image screen you have a number of options These options are outlined below Save Clicking Save saves the document and takes you back to the Scan Document Images screen Shown below in Figure 5 Figure 5 Scan Document Images screen CPI Pg 13 Change Document Change Patient Hain Menu ocan Next Page Options in the above screen allow you to e Scan another page for the current document e Choose a different
59. Clear Clear All Refresh Save Gen pDoc 187 677 11 08 56 NOTE You can select an order for your impressions in the above screen by using the up down arrows to select the impression then clicking on Add The report will appear similar to the one in Figure 6 Pg 122 121 Figure 6 Report Radiographic 2 Impressions Ordered Report Radiographic 2 2008 01 47 51 doc Compatibility Mode Microsoft Word DP 080520144145 view Add ins 7 One Page 1 Views fade trp Side suis Suns M A z dj two Pages ux c Lit Synichranwus Seruiing zz ateen Web Outline oom 100 ew Arrange Spit Swite Reading Layout Meviege Re SD Pege Width window ll dd Beret Window Puilban wing e Zaom Window Exam Date 01 07 2008 RADIOGRAPHIC EVALUATION Radiographic studies of the cervical and lumbosacral spinal regions were obtained in this office 0n 01 07 2008 Cervical Spine Radiographic Examination of the cervical spine utilizing views taken in the A P APOM and Lateral projections demonstrates the following The vertebral bodies arches and processes are noted as normal in size and shape No evidence of degenerative osteoarthritis is present There appears to be moderate intervertebral disc space narrowing at the C4 C5 level Anterior intervertebral disc wedging is noted at C4 C5 At the C4 level anterior listhesis of the vertebral body is observed Instability at the C4 C5 level is noted during flexion and extension T
60. DOCUMENT PLUS USER MANUAL And Tutorial Revision 10 Please read the information enclosed to fully understand the forms and the program If you are in need of further assistance or would like to schedule training Please call 800 642 0600 or 770 814 2442 DocumentPlus P O Box 820 Duluth GA 30096 800 642 0600 or 770 814 2442 Fax 770 814 9988 DOCUMENTPLUS USER MANUAL Copyright 02007 DocumentPlus Technologies Inc All rights reserved 5535 State Bridge Road Alpharetta GA 30022 800 642 0600 770 814 2442 Printed in the USA Trademarks DocumentPluso is a registered trademark Copy and Use Restrictions This software is protected by the copyright laws that pertain to computer software It is illegal to duplicate or distribute this software The software contains trade secrets and in order to protect them you may not decompile reverse engineer disassemble or otherwise reduce the software to human perceivable form You may not modify adapt translate rent lease or create derivative works based upon the software or of any part thereof CONTENTS Introducing Document Plus please hold down Ctrl while clicking on link Learning Document PluS cioe ce ccia veces 221096009999 20 008 0 0uF e 2d EPIS MEUM PNEU ID NM UNE 5 PUDONG AIAG IV FADIA E M 5 db ruso FICE EET T E E tennewesctenseusssesions 6 Document Uus SUDDOEL oue rrea er nenene EEEE
61. ENDIX E Clinical Evaluation 3 INSTRUCTIONS This section is designed to offer explanations regarding the Clinical Evaluation 3 CE3 Form and how to properly complete the form The following instructions cover the form section by section It is our recommendation that you refer to the CE3 form while reviewing these instructions The Clinical Evaluation can be used as a Re Evaluation form as well Choose the appropriate bubble at the top of the form If a bubble is not selected the system will look to see what forms you have on file and select it for you If there is no previous CE on file the program will assume that the unmarked form is an initial CE clinical evaluation If there is a previous CE on file the program will assume that the unmarked form is an RE clinical re evaluation NOTE 1 Only marked bubbles sections will appear in the written report If you skip a section nothing will be written in the report automatically For example if you want a test to be described as Negative in the written reports it must be marked as negative on the form or nothing will be written NOTE 2 Queries are discussed in the User Manual These are responses that the programs expects you the user to input from information or findings that you have gathered and hand written on the form You can set the system up to always use the same response each time you choose the bubble for a query You may also enter multiple entries to creat
62. Era 6 AEE E E T E E 6 Technical 5 WOE eieren EER Ra 6 Scanner Warranty Information ccccccccccccccccccscccccccccccccssssccssssnss 6 E ECO AEE E E DU PNEU EMINENS 7 Computer Requirements sssssessessescoeccccesesesossoeccceesssesseeseecceseseoceee 7 Prep abn Your COMPO seseina LIO EAE T E E E E 8 Current Interfaces with Practice Management Systems c c eene eee ee Ordre OU IMIS n S EE 9 The TONS OY Ch VIOW oedio2292 arrenar ex cecenmnerssuacsucsiiisesessteeaanssneceusee 9 Section A Initial Setup Settimo Up Document PluS lt pi accsoccereussxtescsxsancsemneseeeitieinatintecesctwminesseecesse El Section B DocumentPlus Tutorial I Basic Coue Doca menm CIU ee 11 Step 1 Setting Up Your Practice Demographics 12 22 Entering Information into the Doctor Database 12 15 Entering Information into the Attorney Database 16 Entering Information into the Insurance Database 17 Entering Information into the Patient Database 18 22 dsueHEIInnPEuSge TREE P Scan the FOrmMS sssccccccccccccccccccccccccccccccccccccccccccccccceoeccocococococosoo 24 25 Validation WARNING sssscesssssccsccccccccccccccccccccccccccoseecosoocococococososoose 2 Validation ERROR ssssssscscsccsccoscoocooocoossoccoos
63. Exclusive 14 50 10 56 2 If you have set your default query option to Document you will be prompted to enter the queries now Refer to Completing the Query Screens on pages 32 33 for help 3 Once the queries have been entered your daily note report will be generated automatically Figure 16 Generated Daily Note Report SAMPLE Ee Mr Bob Jones Daily Progress and Procedural Notes January 15 2012 Attending Physician Doctor Your D C SUBJECTIVE Mr Jones complains at his appointment today that his principal complaints are as follows The patient is aggravated by a severe grade of sharp shootmg pam with stiffness and soreness which occurs frequently in his neck on the nght side In his neck on the left side he has a severe degree of shooting pam with stiffness and soreness that occurs frequently The patient notes that the pam with stiffness and soreness remains unchanged in both sides of his neck Ona visual analog scale of 0 to 10 with 0 being no pam and 10 being the worst pam possible he reports his overall pain is an 8 The patient states that his symptoms are worse m the moming and when standing for prolonged penods of time The patient was mstructed to fill out the Pam Diagrams mdicatmg each body area they expenence pam He wasalso shown how to place a number that specifies the level of pam and percentage of the day that pam occurs He relates that he has not had any new provocative incident The patient a
64. G1 f F DocumentPlus 9 010A Modify PreDefs MODIFYPREDEFS EXE WkSta ServerActy HQ 3a Sheet 2 Front Forms Report af x 2 3 2 3 4 Bottom Top m S Exit Fever continuous lt gt skin Itching Golf co lennis co Strength raining c Loss Of Sleep co Skin Dryness Other lt gt Chills co ntinuous c Ecze ma red inflamed skin G MEDICAL HISTORY Modify PreDefs 1 HEALTH CARE Location HQ83 GTF GTF Y Yes Supplements List a Have You Ever Been To A Chiropractor Yi Text ld List mi GITE aj b Do YOU HaveA Family Physician multis Date Of Last Physical Exam Physician s Name Address Have You Been Hospitalized In The Past S SS _ magnesium __ melatonin Date amp Reason For Hospitalization gl Text Id Edit mutivtamins Always Use TravelCardIid Bill Code c d Have You Ever Had Surgery Date Reason Results Of Surgery e Predefined Text Zu Sports Injury Add Delete Report Location Close Cancel Other c Inability To Hold Urine ee re You Currently Taking Any Vitamins co Frequent Urin ation inerals Or Herb s List Supplements Have You Ever Had A Serious Acci dent Inju ry 55 e List Date amp Describe Injury Auto Work Related lt Mouth Sores c Urinary Retention lt gt Bleeding Gums c Bed wetting 3 Click Add and type echinacea 4 Clic
65. Query screen will appear Fig 25 Pg 32 Refer to Queries Pg 32 for information on properly entering queries 4 Once the queries have been entered the Initial Patient History summary will be generated When finished you may exit the document a Reports you can generate are in bold letters Those that are grayed out CANNOT be generated Those forms have either not been scanned have failed validation errors or do not belong to the current case b The information contained in the Initial Patient History summary comes from the initial Health Questionnaire HQ Form This can be generated and printed for the doctor prior to seeing the patient c When generating the Initial Patient History summary you may receive a validation warning when the patient has not properly filled in all the information on the HQ form You may Continue past these errors When the summary is printed you will find a section at the end of the summary titled Corrections to Health Questionnaire Simply give this section to your patient have them answer the questions and return it to you Correct and re scan the form 28 B GENERATING DOCUMENTS CONSULTATION NOTES Consultation Note Overview Consultation notes are comprehensive professionally formatted narratives for your Doctors personal referred to and referred from Insurance Companies and Attorneys NOTES a A Health Questio
66. Record EOF 11 Record Unlock 15 30 46 Complete the following steps to customize the Consult Notes screen 1 CE 0 2 Race Demeanor Posture Head Eyes and Thorax When using the Clinical Evaluation 2 CE2 form this will allow you to include your findings on the selected variables in your daily note report If you do not want to be queried for these in your documents de select any or all of the options prior to scanning forms 2 INS History of Accident This will include a History of Accident section in all insurance documents If you de select this option the History of Accident will be precluded You must do this PRIOR to scanning forms 3 Pain Modifiers If selected pain modifiers mild moderate and severe will appear in the reports If unselected the modifiers do not appear Default 1s selected 75 4 OM If Dates Administered is selected the software will assist you in selecting the treatment dates for the Outcome Measure sections during the document generation process If you de select this option you must manually select the dates prior to document generation It is recommended that you leave this option selected If NP RO Activities is selected specific activities from the Roland Morris and the Neck Pain Disability forms will be listed in your reports De select this option and a single sentence will summarize your findings 6 Signature If Proofed is selected document prepared but
67. References Mimp Review Ae Adde E iei is mmm Qe falSoem Web Oufiew Du ere m lue 10 aoe Lye Radiographic Evaluation Summan IMAGES OF PROJECTIONS Cona ee ee Cervical Lateral 123 APPENDIX I Word Processing Microsoft Word 1 From the Main Menu click Generate Documents 2 Select patient Bob Jones 3 Once in the Generate Documents screen for Bob Jones click to check the box next to Initial Patient History 4 Click Generate 5 Once the Initial Patient History is generated and appears as a Microsoft Word document maximize the active window by double clicking on the title bar 6 Print the document using the printer icon on the toolbar or click File then Print 7 Click Ok to print one copy Repeat steps 3 7 for any other documents you would like to generate and print 9 Once you have reviewed your documents close using the DocumentPlus icon looks like a hand holding a pencil located under File or close Microsoft Word 10 Click Main Menu in the Generate Documents screen to return to the Main Menu Word Documents As Listed in Document Plus insurance erm PO 124 Microsoft Word Saving Reports Original reports are automatically saved Any changes made to the document after it has been generated in word will need to be saved Follow the instructions below to save your reports for future editing and printing 1 While the
68. Therapy section 16 Locate the Rehab Therapy section on the screen image of the DN3c form Page 2 bottom center 59 17 Locate the Cervical column within this section 18 Click on the green bubble at the bottom of the Cervical column 19 The smaller Modify Predefs screen will appear The Location box should read DN 3 TODAY S TX Rehab Therapy H2B1 30 Cervical 20 Click Add 21 In the Text ID box type PNF Stretches SCM 22 In the Travel Card Id box type PNF SCM 23 In the Predefined Text box type PNF stretching was performed bilaterally on the SCM muscles 24 Click Save The next bubble we will predefine is the 1 bubble in the Man Adj section 25 Locate the Man Adj section on the screen image of the DN3c form Page 2 bottom right 26 Locate and click on the 1 bubble within this section 27 The smaller Modify Predefs screen will appear The Location box should read DN 3 Man Adj Misc H3D O1 Other 1 28 Click Add 29 In the Text ID box type multivitamins 30 Click Save The last bubble we will predefine before printing the travel card is the A1 bubble 31 Locate and click on the A1 bubble on the screen image of the DN3c form Page 1 lower left corner 32 The smaller Modify Predefs screen will appear The Location box should r
69. Within each of the technique bars you will find bubbles 1 2 3 These bubbles are for predefining additional techniques You may program in up to 99 different items into the 1 2 3 bubbles Any item predefined for a particular one of these bubbles will be available under the same number in all sections When predefining this bubble the new technique should be entered into the Text ID box For this area it is not necessary to enter information into the Predefined Text box You may also want to add a Travel Card Id This information will appear in the Adjt box on your printed travel card and should be entered as a recognizable abbreviation for the specified technique The SOAPT 1 bubbles are for adding information to your daily note report that there is not another bubble on the form for When predefining the SOAPT 1 bubbles information should be entered in the form of a complete sentence using capitalization and punctuation The information will appear at the end of that particular section exactly as it was entered Example Predefined information for the S1 bubble will appear at the end of the Subjective section in your daily note report The SOAPT 2 bubbles are for adding in office information that will print only on the travel card When one of the SOAPT 2 bubbles is marked on the form and once the form 1s scanned a query screen will appear prompting you to enter the information for y
70. ability Questionnaire RM Outcome Measures Revised Oswestry Low Back Pain Disability Questionnaire RO Health Status Questionnaire HSQ Neck Pain Disability Index Questionnaire NP Patient Letters Consultation Notes Attorney and Insurance Doctors REPORT REQUIRED FORMS REPORT REQUIRED FORMS 37 Section C DocumentPlus Tutorial II Daily Note Travel Card DAILY NOTE and TRAVEL CARD SYSTEM Introduction The Daily Note Travel Card will replace your existing travel card It can be customized to accommodate your practice protocol provides the ability of viewing the five most recent visits and is designed to meet Managed Care and Medicare Guidelines Features have been added that allow you to customize the form to fit your needs This Daily Note Travel Card system surpasses anything else currently available This tutorial was designed to give you an understanding of how the daily note and travel card system works and how it can be fully utilized in your practice If you have completed Tutorial I you are ready to proceed If you need further assistance after completing Tutorial IL please call 800 642 0600 to schedule a training session Overview The first time you treat a patient you will fill out a daily note form DN3c in its entirety The form is scanned and the information 1s saved 1n Document Plus When the patient comes in for a second visit the information from the previous visit is printe
71. al spine are normal and the normal degrees will be listed If you find that all ranges of motion are normal with the exception of one or two you can mark the Normal In All Positions Except bubble and choose the deficiencies found You may also just mark a particular range of motion tested and skip the rest 103 O O The numbered bubbles in each of the ranges listed represent degrees Tens may be combined with Units Though it is not required if you choose to mark the bubbles for additional descriptors associated with the range of motion you may choose either Dull Pain or Sharp Pain and not both If you mark either Spinal Level Of or Radiates To a query will appear The query must be answered for the system to complete the report e Cervical Muscle Testing D1b O Both Left and Right may be marked If you mark the No Muscle Weakness Except bubble you do not have to mark anything else in the section The report will reflect that all cervical muscle groups listed on the form were tested and were found to be grade 5 5 and intact If you find all are normal with the exception of one or two you can also mark the No Muscle Weakness Except bubble and select up to TWO abnormal findings For Reference 0 5ZNo muscle movement 1 5 Visible movement twitch but no movement at the Joint 2 5 Movement at the joint but not against gravity 3 52Movement against gravity but no added resi
72. any combination of Practice Name Doctor s Name and or Address to appear in the footer of your reports Signature e Underline This feature will insert a signature line at the end of the document s selected e Summary If Form is selected the doctor s signature is pulled from the doctor number bubbled on the form If Current is selected the doctor s signature is pulled from the Doctor field on this screen If you need further assistance with customizing the Advanced Setup screens please contact our training department at 800 642 0600 78 There are a number of items on the DN3c form that can be customized to meet the specific needs of your practice You may choose to Always Use a specific item when the corresponding bubble is marked or you may create pick lists so that when the forms are scanned you have the option of choosing from a number of entries for a particular bubble This section outlines items that can be predefined according to the area on the form in which they are located To customize the daily note form DN3c please follow the Modify Predefines instructions below From the Main Menu in Document Plus 1 Click Utilities Select Modify Predefines Click on Daily Note Double click DN 3 An image of the DN3c form should appear on the screen S E a Items that can be predefined are colored green or turquoise On your screen click on the
73. area An image of the completed Pain Diagram will appear in your daily note report See Figure 3B Pg 42 To have the following sentence appear in the Subjective section of ALL daily note reports select Pain Diagram Instructions under the Daily Notes 2 tab in Setup The patient was instructed to fill out the Pain Diagrams indicating each body area they experience pain He was also shown how to place a number that specifies the level of pain and percentage of the day that pain occurs lf you use this sentence make sure that the patient has been instructed to fill in the pain diagrams in a way that 1s consistent with the instructions indicated in the sentence This sentence can be customized in the Modify Predefines screen for DN 3 No New Aggravation Injury This statement references the initial clinical evaluation and by marking this bubble you are basically stating that there has been no change regarding injuries since the initial evaluation New Injury This bubble should be marked when a new injury or an exacerbation of an old injury occurs New Injury should be used in conjunction with New Additional in the Assessment section so that both new injury information and new diagnosis codes are documented Signature and Date To provide proof that the patient was in the office did receive treatment and that the symptom information 1s accurate the patient should provide a signature and
74. area of the body tenderness is radiating to For example If Radiate is marked in the thoracic region and upper extremities are also marked the conclusion is that the condition radiates into the upper extremities Radiate can be bubbled without a radiate to location The text would simply state that the tenderness radiates The sacral and pelvic regions can radiate downward into the lower extremities but do not radiate upward Posture This section is used to document postural deviations Forward Flexion Forward Flexion can be documented in the cervical lumbar or both Range of Motion When Decreased range of motion is bubbled you must indicate the level of pain associated with that area Mild Moderate or Severe 27 Turn to Page 1 and locate the Objective section on your form See Figure 11 Pg 51 28 In the Leg Length Deficiency section bubble Right 1 8 shown in Figure 11 Pg 51 29 In the Biomechanical Exam section Bubble the following areas as shown in Figure 1L Po 51 a Onthe LEFT side in the CERVICAL area draw a heavy line down through upper U Middle M and lower L in the Sublux and Spasm columns b Onthe RIGHT side in the CERVICAL area draw a heavy line down through upper U middle M and lower L in the Sublux Spasm Tender Inflammation and Radiate columns c
75. as it appears in the daily note report for ten minutes Example of what you might enter in the Text ID box PNF SCM strengthening Rhomboids resistance bands wrist ext Example of what you might enter in the Predefined Text box PNF stretching was performed bilaterally on the SCM muscles Rhomboid strengthening exercises using 3 lb weights were performed To strengthen the wrist extensors resistance bands were utilized You may also want to add a Travel Card Id This information will appear in the Thrpy box on your printed travel card and should be entered as a recognizable abbreviation for the rehab therapy performed 82 Pillows 1 2 3 These bubbles can be used to enter three different therapeutic or support pillows Information entered here will appear in the Plan section of your daily note report and be preceded by The following was prescribed or followed by was prescribed Examples are outlined below Example of text as it appears in the daily note report Multiple items bubbled The following were prescribed this session Single item bubbled This session was prescribed Examples of what you might enter to complete the above statement a lumbar support pillow a cervical alignment pillow Other 1 6 These bubbles can be used to enter nutritional supplements and other items recommended or prescribed for a patient Inf
76. as produced during the test If the Other bubble is marked it supersedes all other options and a query will appear Kemp s Test D3b3 Only one choice of Negative or Positive may be marked Both Left and Right may be marked Additional bubbles may be marked to indicate where pain was produced during the test There can be only one choice marked for either Leaning Into or Leaning Away e Mechanical Tests D3c SI Sacroiliac FABERE Patrick s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test o Gaenslen s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test 107 o Thomas Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test o Yeoman s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test o Hibb s Test Both Left a
77. as well as a patient s functional status The Outcome Assessment questionnaires should be administered based on patient histories and your examination re examination findings to provide a detailed assessment of the patient s progress over time Used properly the Revised Oswestry Low Back Roland Morris Acute Low Back Neck Pain Disability and Health Status Questionnaire forms can prove to be valuable outcome assessment tools for your practice This section is designed to give you an understanding of what each of these forms is used for and when they should be used Utilizing Outcome Assessments in your office is a simple process First have the patient complete the Outcome Assessment Questionnaire Next your staff will scan the questionnaire into the system and the data is incorporated into reports for the patient insurance companies and or attorneys In a matter of minutes you will have established validity responsiveness and reliability of treatment To properly incorporate assessment questionnaires into your normal office protocol you must be in compliance with the following Administer the questionnaire to the patient produce the outcome assessment report independently or as part of the report of findings schedule a time for an outcome assessment consultation and review the report with your patient The billable code for an initial visit is 96150 and on a subsequent outcome assessment i e re exam the code is 96151 Th
78. atient is responding to treatment and some improvement has been noted Other Other is located in the Response to Tx in area of the Assessment Progress section This bubble may be used to document an increase e g increase in work ability or a decrease e g decrease in hypertonicity or to list items such as soreness or edema To predefine this bubble follow the eight steps at the top of Pg 79 and type entries into the Text ID box only clicking Add between each entry Click Save Close when finished Example of text as it appears in the daily note report dti bs my observation that the response to treatment results in a 20 increase reductions in Examples of what you might enter to complete the above statement increase in work ability 23 66 decrease in hypertonicity soreness and edema Other 1 Other 2 Other 3 These three columns allow the entry of additional modalities used in your practice You may enter up to 99 different modalities for any of the three columns If you choose the Always Use option for a modality the system will automatically use the item when you mark a bubble in that column You may also want to add a Travel Card Id This information will appear in the Thrpy box on your printed travel card and should be entered as a recognizable abbreviation for the treatment or modality When predefining items in
79. ay a malposition was found at the T1 level With the box checked the report will say a subluxation malposition was found at the T1 level Finally as with the other sections on the form there are two bubbles at the end of each section labeled as None and Note Cervical Thoracic Lumbar Sacro pelvic If None is marked for a particular section then the report will reflect for example No edema spasm or tenderness was found over the upper middle or lower regions of the cervical spine Note is also at the end of each section to enable you to add an additional note or finding to the specific spinal region a query will be generated Algometer If this section is used you must indicate on the form if the readings were taken in PSI or Kgs cm Anything marked in this section will prompt you to enter the information via the query screens Both sections for the Upper Extremities and Lower Extremities are driven entirely by query input Any bubble marked will generate a query so that you may enter an explanation of your findings They must be entered for the system to complete the report 110 In this section you may mark as many diagnoses as you feel necessary to complete your report You may choose only one and designate the diagnosis as either Primary Secondary or Other The Other designation is used for Medicare in which case if marked you may designate a condition as somet
80. b Do You Have A Family Physician oS vate Of L ast Physical f hysician s Name Address owe c Cycling lt gt Swimming lt gt Strength Training xam Phon ef Have You Been Hospitalized In The Past d ate amp Reason For Hospita lization Have You Ever Ha d Surgery 6 Ne ate Reason Results Of Surgery Have You Ever Had A Serious Acci dent Inju ry E9 Ng ist Date amp Descnbe Injury ae Auto VVork Related Personal Sports Injury Other Are You Currently Taking Any Vitamins Minerals OrHerb s List Supplements Are You C urrently Taking Any Medications es For Vhat Condition s Are You Taking Medication pnti inflamrm atory Aspirin Ibuprofen Motrin etc On your screen locate Pg 3 Section G Question 1f Are you currently taking any Vitamins Minerals or Herbs We will create a pick list of common supplements to choose from when entering this query 34 NOTE Use the left right arrows at the top of your screen to navi e and the up down arrows on the right to scroll from top to bottom FA DocumentPlus 9 010A Modify PreDefs MODIFYPREDEFS EXE WkSta ServerAc Foms Repot gt 1 2 gt 4 Bottom top f 4 Exit 2 Click the Yes bubble for question G1f You will see the Modify PreDefs screen Figure 29 below Figure 29 Modify PreDefs
81. bubble of the item you wish to predefine 7 A smaller Modify Predefs screen will appear Click Add and enter your text according to the instructions outlined below Other Other is located in Section I under If your symptoms change when are they worse This bubble is used to indicate other times of day or conditions that aggravate a patient s symptoms To create a pick list for this bubble containing common entries follow the eight steps above and type entries into the Text ID box only clicking Add between each entry Click Save Close when finished Example of text as it appears in the daily note report The patient reports that his symptoms are worse j a2 66 Examples of what you might enter to complete the above statement when bending when lifting during recreational activities and before getting out of bed New Injury New Injury 1s located beneath the Pain Diagrams in Section II A patient would use this bubble when a new injury or exacerbation of an old injury has occurred To create a pick list for this bubble containing entries for common injuries follow the eight steps above and type entries into the Text ID box only clicking Add between each entry Click Save Close when finished Example of text as it appears in the daily note report He indicates Examples of what you might enter to complete the above statement are
82. bular Joint Syndrome 721 0 Cerv Spondylosis Cervical Spondylosis 722 0 Cerv Disc Disp Hern Cervical Disc Displacement Herniation 722 4 Cerv Disc Degen Cervical Disc Degeneration 723 1 Cerv Spine Pain Cervical Spine Pain J23 2 Cerv cranial Syn Cervicocranial Syndrome 723 3 Cervi brachial Syn Cervicobrachial Syndrome 723 4 Cerv Radi Root Comp Cervical Radiculitis Root Compression 729 1 Cerv Myofascitis Cervical Myofascitis 739 1 Cerv Seg Dysf Sublux Cervical Segmental Dysfunction Subluxation 756 10 Cerv Congenital Anom Cervical Congenital Anomaly 847 0 Cerv Sprain Strain Cervical Sprain Strain 353 8 Thor Intrcost Neuritis Thoracic Intercostal Neuritis 354 8 Thor Scapcost Syn Thoracic Scapulocostal Syndrome 721 2 Thor Spondylosis Thoracic Spondylosis 722 11 Thor Disc Disp Hern Thoracic Disc Displacement Herniation T2251 Thor Disc Degen Thoracic Disc Degeneration 724 10 Thor Spine Pain Thoracic Spine Pain 724 4 Thor Radi Root Comp Thoracic Radiculitis Root Compression 729 1 Thor Myofascitis Thoracic Myofascitis 739 2 Thor Seg Dysf Sublux Thoracic Segmental Dysfunction Subluxation 737 10 Thor Kyphosis Thoracic Kyphosis 731 30 Thor Scoliosis Thoracic Scoliosis 756 10 Thor Congenital Anom Thoracic Congenital Anomaly 847 1 Thor Sprain Strain Thoracic Sprain Strain 848 3 Thor Rib Intrcost Strn Thoracic Rib Intercostal Strain 133 721 3 722 10 722 52 724 02 724 2 724 3 724 4 724 8 729 1 739 3 756 10 756 10 847 2 715 15
83. creen Your screen will appear blank since no patients have been entered into the database Figure 2 Pick Patient screen d amg FA DocumentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv PE X EI Pick Patient m H LIMIN VIWIXIY IZ V olPloiRisiTiu EA Attorney Pickpati c docplus9 010 dbfsserverspickpati dbf Record 1 1 Record Unlock 2 Click the Doctor button See Figure 2 above 12 NOTE You are now in the Pick Doctor screen See Figure 3 below Figure 3 Pick Doctor screen r FA Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv E Pick Doctor ee 7 Cla Doctor s Name Your Doctor D C t Ok New Main Menu Insurance R tor Tepe I Ckidno c docplus9 01 O dbf server ckidno dbf Record 4 6 NUM 10 48 38 3 Double click to select YOUR doctor s name See Figure 3 above NOTE You are now in the Doctor Information screen See Figure 4 below 4 Verify your doctor s name credentials address and phone information Figure 4 Doctor Information screen In House r FA Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv Doctor Information Dr Doctor Your D C 001 Information 1 Information 2 l Name Type In House gt ID Number 001 PMReE Title First name Middle Last name Credentials Dr Doctor 1 yexr
84. d onto a BLANK daily note form That daily note form then becomes a travel card which you will use for that day s visit What you will need THREE 3 BLANK DAILY NOTE FORMS DN3c Rex Pin 1215 Sena wk vesereourtuo0r 20404081 amelana Da mus Patient Nome Jones Bob 3 Ade Me C5 C8 MO DAY YR DR SHer 3p St DF 1 hrpe toe 15y UML Canr ENS 10 ay Gore N C 1 Cav P Tr pci VAS 7 8210 T 10 STEP 1 Filling out the Daily Note Form DN3c INITIAL VISIT We will now fill out a Daily Note form for Bob Jones patient 3 first visit Use a 2 pencil when bubbling information onto the form DATE DR PATIENT NUMBER 1 Using Figure I below as a guideline fill in a date on your form at least TWO days prior to today s date 2 Bubble Doctor 1 and Patient 3 onto your form as shown in Figure 1 below NOTES a This section must be completed for each visit b Please note that in the DAY column the top section of bubbles reflect units of ten and the bottom numbers reflect units of one c In the year column YR it is only necessary to bubble the one or two digits representing the year 2000 is assumed e g If the year is 2008 only the 8 should be bubbled d In the DR and Patient Number sections the numbers should be bubbled in columns farthest to the right 39 SYMPTOMS The information from this section on the form makes up
85. date in this section on each visit An image of the signature and date will appear in your daily notes shown in Figure 3B Pg 42 6 Locate Symptoms Section II on your form See Figure 3A Pg 42 7 Bubble 8 in the pain scale as shown below in Figure 3A Pg 42 8 Bubble Morning for the question If your symptoms change when are they worse 9 Copy the information from Figure 3B Pg 42 to the Pain Diagrams section on your form 4 SECTION li How Would You Rate Your Pain Tonay Witt 0 Being The Best And 10 Being The Worst e If Your Symptoms Change When Are They Worse Morning Evening Afternoon Night Other XAR iei S uk Please Mark The Location Of Your Pain On These Figures PAIN DIAGRAMS Please Mark The Location Of We Pain On These Figures No New Aggravation Injury New Injury PATIENT SIGNATURE DATE Pob bas DATE HES 3rof Figure 3A Figure 3B 42 ASSESSMENT The Diagnosis and Progress sections make up the ASSESSMENT portion of your Daily Note report If you do not bubble anything here you will NOT have an Assessment section in your daily notes Assessment Diagnosis The diagnosis section references the Clinical Evaluation that is done on the patient s initial visit 10 Locate Assessment Diagnosis on your form see Figure 4 below Previous Unchanged When bubbled you are basically noting that there have been no changes in diagnosi
86. ded for you to add in your own tests Please see explanation of queries and predefined text for explanation Deep Tendon Reflexes Both Left and Right may be marked If you mark the Grade 2 and Symmetric Except bubble you do not have to mark anything else in the section and the report will reflect that all upper or lower nerve root Deep Tendon Reflexes are intact However if you find all are normal with the exception of one or two you can also mark the Grade 2 and Symmetric Except bubble then select up to TWO abnormal reflexes For Reference 0 Absent 1 Hypoactive 2 Normal 3 Hyperactive without Clonus 4 Hyperactive with Clonus 5 Tonic Motor Examination Upper Extremity Motor Function o Both Left and Right may be marked o If you mark the No Muscle Weakness Except bubble you do not have to mark anything else in the section and the report will reflect that all upper nerve root motor functions are grade 5 5 and intact However if you find all are normal with the exception of one or two you can also mark the No Muscle Weakness Except bubble and select up to TWO abnormal functions Lower Extremity Motor Function o Both Left and Right may be marked o If you mark the No Muscle Weakness Except bubble you do not have to mark anything else in the section and the report will reflect that all upper nerve root motor functions are grade 5 5 and
87. dysfunction subluxation are identified as follows The perception of pain and tenderness is evaluated in terms of location quality and intensity Most primary neuromusculoskeletal disorders manifest primarily by a painful response Pain and tenderness findings may be identified through one or more of the following observation percussion palpation provocation etc Furthermore pain intensity may be assessed using one or more of the following Visual Analog Scales algometers pain questionnaires etc Documented on our DN FORM in the symptoms section PG2 The 5 columns in the symptoms section represent what Medicare wants to know about the symptoms Beginning in the 1 column we have the TYPE of problem SEVERITY of the problem CHARACTERISTICS FREQUENCY and WHETHER OR NOT THE PROBLEM IS IMPROVING Also documented using the PAIN SCALE VAS and the PAIN DIAGRAMS FROM THE DOCTOR S EXAM Document in the objective section using the TENDER and RADIATE columns under biomechanical exam PG1 Figure 1 Symptoms Section1 DN3c Form Pg 2 2000121910 If Your Symptoms HAVE NOT Changed Since Your Last Visit Indicate Here And Proceed To Section liam If Your Symptoms HAVE Changed Since Your Last Visit Please Complete Both Sections and Il SECTION s A aad RIGHT Fi FP c ae Se QUU X a a se A wm Head W rre wm Neck mm Upr Back wm Mid Back wmm Low Back Shoulder wm Elbow wm Wrist wm Hand mm Hip em Kn
88. e shown below in Figure 6 Figure 6 Plan Section Page 2 Right DN3c Form Per Initial Prev Plan lt gt Changed As Follows Additional Recommendations Home Care Instructions Observation Re Exam e Res Moist Heat X Ray Other ice Gen Measures Addt l Diagnostic Testing Exercise Visit Schedule Other Daily gt lt Weekly e Monthly lt gt PRN Visits This Plan ela 6 oo 5c Exam New Patient Established Established TX Consultation Level Level Il Level lil Level IV Level V TODAYS TREATMENT Modalities The information from this section appears as part of the TREATMENT portion in your daily note report Mark only the modalities that were performed There are three other bubbles in this section These bubbles can be user defined for any modalities used in your office and not listed across the top of this section You also have the option to specify if the treatment was attended and for how long If you do not wish to mark a treatment as attended simply leave the Attend bubble empty You may bubble multiple time increments for therapies lasting longer than 30 minutes The system will add them together automatically e g If massage was performed for 1 hour you would bubble 30 15 10 and 5 17 Locate Today s Treatment Modalities on your form see Figure 7 below 18 Draw a heavy line down through the upper U middle M and lower L cervical area
89. e a pick list for a particular bubble If you have any questions after reviewing the Queries section in this manual please feel free to contact our training staff at 800 642 0600 SECTION A Physical Examination gi d ui RR Demeanor e Make one selection for Coherent or Incoherent e Make one choice for Distressed Mild Moderate Severe e If you choose Relaxed you cannot choose the Nervous Agitated or Disinterested bubbles e If you bubble Other all other bubbles will be ignored as the information you enter in the query will supersede any other thing marked in the section A27 SAT Leere Vital Signs If All Vitals Stable is marked the written report will reflect that the patient s vitals are stable but will not give specific numbers You may mark this bubble and still use A2 A7 to document specific numbers For example the report will look like this Vital Signs All Stable Height 5 10 Weight 220 pounds Temperature 98 6 F Pulse 60 minute and regular Respiration Rate 15 minute 99 A2 Height Mark one bubble for Feet and one for Inches A3 Weight Mark one bubble per line for Hundreds Tens and Units A4 Temperature Mark one bubble per line Pnts Points in temperature Ex 98 6 A5 Pulse Choose either Regular or Dysrhythmic One bubble per line f
90. ead DN 3 Of Additional Note I F4 1 Assessment 33 Click Add 34 In the Text ID box type Range of Motion Cervical 35 In the Predefined Text box type Tests indicate an increase of 5 in cervical range of motion since initial evaluation 60 36 Click Save then click Exit at the top of the screen The Travel Card is a feature that allows doctor and staff to view specific information about a patient s previous visit s and can be printed prior to the patient s next visit Information printed on the Travel Card includes Diagnosis and X Ray information from the initial visit or re evaluation Symptom and treatment information from the previous visit Re evaluation and X Ray retake dates Visit and plan information Notes section for in office communication 1 From the Main Menu click on Travel Card The Print Travel Card screen will appear shown in Figure 17 below Some important features in the Print Travel Cards screen are outlined in red in Figure 17 and explained below The asterisk to the left of the patient name indicates that this patient is selected and a travel card will print for him her Clear All By default ALL patients in the list are selected This feature allows the option of clearing all of the selected patients Mark on Form This section allows the option of pre printing the doctor number patient number
91. ecececececesececeseseeeseseseseseee 99 113 Appendix List PUN CHONG si sssicicscadsscassesiccesteadessdaedscistcadsdaisasnsccestesdesssasdscicsess 114 116 Appendix G Utuli es PUN CHONG oi icsicccdeccteccncessccecescdecsacesicdedesstecencesacdecesecestacetes 117 118 Appendix H Including Images in your Radiographic Report 119 123 Appendix I Word Processing sisiseccsctsisscetesesicssdscescessianvecscetsdeetesedeestlsesuesssianveast 124 125 Appendix J ADbDreviations 2 5 9 12 2 022 2 260124220 9 2020069 910500052208 62122220 222 2 0 0122 126 139 Introducing DocumentPlus Thank you for selecting Document Plus We believe our product and service will exceed your expectations for report writing and documentation DocumentPlus is easy to use and serves as a powerful practice building tool Use it to produce a variety of professional reports for patients attorneys insurance companies and other doctors Learning DocumentPlus DocumentPlus is easy to learn and use This tutorial will provide an overview of the program and give you the basic information you need to get started You will want to watch the training and informational DVDs located in your starter kit or online at www docplus net and complete this step by step tutorial Please call the Document Plus training department at 800 642 0600 to schedule further telephone training About This Manual Introducing Document Plus Sup
92. ed listings from the previous visit will appear The travel card will reflect up to five visits with 1 always representing the most recent visit 65 We will now use the form with the printed travel card information for Bob Jones second visit The purpose of this part of the tutorial is so that you can gain an understanding of when and how the Same As bubbles are used l 2 Bubble yesterday s date in the date columns in the upper right corner on page 1 The 1 should be bubbled under DR and the 3 should be bubbled under Patient Number If the pre printed black squares do not line up you will need to adjust the calibration settings before going any further Please contact our technical support department at 800 642 0600 for assistance Turn the form to page 2 and begin with the Symptoms section Fill in the bubble next to If your symptoms have not changed since your last visit indicate here at the top of page 2 can still make some changes in Symptoms Section I 2 10 11 12 On the RIGHT SIDE Neck area a Inthe second column bubble Moderate b Inthe last column bubble Improving On the LEFT SIDE Neck area a Inthe second column bubble Moderate b Inthe last column bubble Improving Go to Symptoms Section II a Inthe Pain Scale bubble 7 If your symptoms cha
93. ee mm Ankle i wm Foot b d ti m LEFT 8 wm Head Nock Upr Back wm Mid Back a Low Back mm Shoulder Elbow mm Wrist mm Hand mm Hip mm Knee m oo CD cb ch a wm Ankle 9 gt A e ogg x uS 3F CE Ld a amp S S a Su E lt f eS e af e oe eO re co i 9 v eU SECTION II f How Would You Rate Your Pain Today With 0 SBAIN SCALE VAS orst if Your Symptoms Change When Are They Worse WHAT MAKES SYMPTOMS WORSE gt H ONdIAI XAHLAHM 4 6 5 23 4 91 lasal FEX ot C TIBSIETeILET Ej Please Mark The Location Of Your Pain On These Figures 22 ala s 2 ale amp amp Yd JO 9 4 E a o a pS a 1 EN i i lt uu a lt S amp S Sic s T LON A f 2 ala cim s i 2 2 PAIN DIAGRAM IW ISO HO Ad AL ADO Av is 6 u i un ert esr x QS ee ea at a Ni I 3 5 aw M A SOLLSI PATIENT SIGNATURE AND DATE ado 5 No New Aggravation Injury New Injury lt iis ES mXmmES XI _ PATIENT SIGNATURE DATE amp Figure 2 Subjective section Daily Note report Sample Text SUBJECTIVE Bob Jones indicates during his visit this day that his main complaints are the following The patient has in both sides of his neck a frequent sharp shooting pain with stiffness and soreness of a severe level In the right shoulder he is bothered by an intermittent pain with stiffness and sorenes
94. er Exam Date 01 07 2008 RADIOGRAPHIC EVALUATION Radiographic studies of the cervical and lumbosacral spinal regions were obtained in this office on 01 07 2008 Cervical Spine Radiographic Examination of the cervical spine utilizing views taken in the A P APOM and Lateral projections demonstrates the following The vertebral bodies arches and processes are noted as normal in size and shape No evidence of degenerative osteoarthritis is present There appears to be moderate intervertebral disc space narrowing at the C4 C5 level Anterior intervertebral disc wedging is noted at C4 C5 At the C4 level anterior listhesis of the vertebral body is observed Instability at the C4 C5 level is noted during flexion and extension There is an interruption of the spinolaminar junction line at the C4 segmental level The patient s cervical lordotic curve appears to be straightened The surrounding soft tissues and lung apices are normal Lumbosacral Spine Radiographic Examination of the lumbosacral spine utilizing views taken in the A P and Lateral projections demonstrates the following The facet joints appear symmetrical and equal There is evidence of moderate intervertebral disc space narrowing at the L4 L5 L5 S1 segmental levels s sa e om o Pageilofl Wordr298 engash US Images will appear in your reports as shown in Figure 8 Pg 123 122 Figure 8 Report Radiographic 2 Images Sy Che ee D Yer Fageleywet
95. ese are classified as Health and Behavior Assessment Codes and the description of the procedure is as follows An assessment of patient s condition was performed through the administration of various health and behavior assessment instruments Most insurance companies will have these codes in their current database Assuming that both the provider and the payer are following CPT guidelines and protocols and the codes are covered services in an insurance contract and clinically needed payment would be expected NOTE These service codes are for time units of 15 minutes or less Any forms and or questionnaires used are considered assessment tools and are not intended as substitutes for actual professional services rendered by the doctor Remember that you are billing for a service and not for an assessment tool 85 Implementing and billing for Outcome Assessments can be done in three easy steps The process of implementing the use of Outcome Assessments should consist of the following three steps 1 Administer the questionnaire Have the patient fill out the appropriate questionnaire 2 Scan the questionnaire and create the report After the patient has completed the questionnaire scan it and generate the related outcome assessment report NOTE Information from questionnaires administered on the Initial visit will appear in the Initial Report of Findings document Information from questionnaires administered on a subsequent vi
96. etting Your Preferences Overview The Document Plus system offers many customization options for daily note reports narratives and screen defaults A number of those can be selected in the Setup portion of the software This section outlines the options under each setup tab Figure 1 Set Up Daily Notes 1 Tab F Document Plus Version 10 00 Miscellaneous MISC EXE WkSta ServerActv S X Setup Information Settings Daily Notes 1 Daily Notes 2 Consult Notes Miscellaneous 1 Miscellaneous 2 Daily Format soaP Report By Name i Report Dates Notes DN 3 Query Document Scan iv Subluxation From Thrust Segment Grp 314 Heading iv Symptoms Status Unchanged Adjustment Reason Subluxation DN 3 Complaints Order From HQ 2 Report v Visits This Plan Adjustments Travel Card Complaints From Include IV CoPay SOAPT2 Default Treatment Billing Layout Sign Note None Attended Signed By Region Adjustment Adjustment Text Cervical v Document Actions Layout Letter Layout Report Save Cancel Prsware c docplusS 010 dbfspm pmsware dbf Record EOF 11 Complete the following steps to customize the Daily Notes 1 screen 1 Format You may choose Paragraph or SOAP 2 Report By Select an option for batch printing of Daily Notes The report will be printed in order of patient Name or patient Number 3 Report Dates Lists daily report
97. f Spouse Child Other ih p Home Phone 813 596 4587 Office Phone 513 559 6542 35648 Co Pay Doctor None NOTE In this screen you can select an insurance company in association with the selected patient If linked here the information will appear automatically in the appropriate fields when generating narratives NOTE This is the screen where you will select the primary insurance carrier for the selected patient 8 Enter the information as shown in Figure 15 above a Relation to Insured Use the pull down menu to select Self This will automatically fill in the patient information Notice You also have the option to select Spouse Child or Other If you select one of these options you may use the Pick button to the right of Last Name to select the primary insured s name or simply type the information into the provided fields 9 b Use the Pick button in the Primary Insurance Carriers section to open the Insurance database and select the insurance company name Click Save then select the Insurance 2 tab at the top of your screen 20 NOTE You are now in the Secondary Insurance Information screen See Figure 16 below Figure 16 Secondary Insurance Information screen FA Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActy Secondary Insurance Information Jones Boh a
98. g back pain and disability Use when patient complains of Acute low back pain 4 weeks or less Revised Oswestry Chronic Low Back Pain Disability Questionnaire This is a subjective questionnaire that quantifies the degree of functional impairment of individuals with chronic low back pain The Oswestry is a well known outcome assessment tool used in evaluating the effectiveness of treatment protocols Use when patient complains of Chronic low back pain more than 30 days Health Status Questionnaire This questionnaire measures eight specific health attributes grouped under three major health dimensions functional status well being and overall health It is used to show overall functional status and is commonly used in personal injury and wellness cases To establish a baseline of overall health the Health Status Questionnaire should be incorporated as part of the routine exam on each new patient and then administered again at each re evaluation APPENDIX C Scanning Images With the Scan Images feature you are able to create electronic Records for your patients You have the ability to scan copies of a patient s driver license insurance card medical records from another office or any other document you want to keep on file 1 On the Main Menu click the lower half of the Scan button next to Images See Figure 1 below Figure 1 Main Menu FA Document Plus 10 00 Ee Databases Sca
99. ged their understanding of them If you mark this bubble this exact sentence will be added to the report 112 1 When you are using the CE3 as a Re Evaluation form make sure that you have a daily note on file for the same day This will cover the subjective section for the Re Evaluation reports 2 Every Orthopedic test can have only a Negative or Positive finding not both 3 Any bubble on the form that says Except can generally have only 2 exceptions with a warning 4 PAIN MODIFIERS on this form when a test is marked as Positive you have a choice of having the report indicate the level of pain experienced by the patient Mild Moderate Severe If you want the modifiers added to the report you must go into the system s set up screen from the Main Menu and check the box for pain modifiers to be added If you do not check this box in the set up screen the report will only indicate Pain as a positive finding If you do have modifiers enabled the report will add the modifier before pain For example the test produced moderate pain CLINICAL EVALUATION 3 CLINICAL RE EVALUATION 3 REFERENCE SOURCES The CE3 RE3 was built using a cross reference compilation of the following reference books NOTE No one test came from a specific source Each test was cross referenced between each of the sources listed below and the most agreed upon definition used for the forms Some additional texts we
100. grade Degenerative Dg grade grade 2112131415 Spls L5 Spc2 Spls L5 Spc2 S12Dg5 Facet Imbrication FcI FcI L4 L5 L5 S1 Other FcI L4 LS L5 S1 Disruption Of George s Line DsGL DsGL L4 L5S L5 S1 Other DsGL ZLA L5 L5 S1 Facet Asymmetry FcA FcA LA L5 z finding L5 S1 finding Other finding finding Right Rt Left Lt sagittal Sag Right Rt Left Lt coronal Cor FcA L4 L5 RtSag LtCor L5 S1 LtSag RtCor Sagittal Diameter Of Spinal Canal SDSc SDSc L4 dia L5 dia Other dia SDSc L4 04 L5 03 Anomalous Transitional Lumbosacral Segment Sactalization Of L5 SacL5 Lumbarization Of 51 LumS1 Right Rt Left Lt Bilateral Bi Neoarthroses Nar SacL5 LumS1 BiNar Section 5 Therapy Modalities Ice Ice Diathermy Diath Hydro Therapy HyTh Moist Heat MHt Interseg Traction IT Mech Traction MT 138 Massage Mss Ultrasound Us Ischemic Comp IC LV Galvanic LV HV Galvanic HV Interferential If Russian Stim RS Myo Rel Myo Re joint mobilization Jt Mob Locations Head Hd UML Cerv UML Tho UML LS Rt SI Lt SI RtU Extr LtU Extr RtL Extr LtL Extr 139
101. he Upper Extremity column bubble Inst 45 In the R column bubble Wrist 46 Bubble Y next to Patient Tolerated Procedure Well This is considered a risk management item and should always be marked When marked a sentence will appear in your daily note report stating that there has been no problem with treatment up to this point TODAY S TX General Listing e Technique Bar The Tx1 section should be used before using ee Tx2 95 53 SOAPT Of Additional Note In the lower left corner of Pg 1 on your form is a section labeled SOAPT 1 amp 2 The SOAPT bubbles are used to insert information into your notes when there is no other available bubble on the form If one of these bubbles is marked a query screen will prompt you to type in any additional notes You have the option of entering the information each time or predefining these bubbles By default SOAPT 1 bubbles will appear only in your daily note report Information entered using the SOAPT 1 bubbles will appear as a complete sentence or sentences in the corresponding section e g If S1 is bubbled the information will appear in the Subjective section in your notes By default information entered using the SOAPT 2 bubbles will appear only in the notes section on your travel card used for in office information The default settings can be changed in Setup Daily Notes 1 so that the
102. her bubble marked in this section e Choose either Left or Right and one choice for measurement e You may combine Supine Prone etc e Cervical Dependant and Pelvic Dependant cannot be combined RS onse Orthopedic Tests B3a Adam s Sign e For Adam s Sign either Positive or Negative may be marked but not both e Functional Scoliosis or Structural Scoliosis may be marked but not both e Sciatica may be marked for both the Left and Right B3b Minor s Sign e Mlild Moderate Severe BA oos Of Additional Note You can enter information for these twelve bubbles each time you want to add additional information or you can predefine lists of customized entries to choose from SECTION C Neurological Assessment Iu Cerebrovascular Function Sections a b and c George s Test Carotid Pulsations Can mark both Left and Right 2 Normal Bruits Can mark both Left and Right e Craniocervical Functional Maneuver or Maignes Test Can mark both Left and Right If you select Findings you will need to enter those findings as a query ul Bo c Cranial Nerves e If you mark the Cranial Nerves Intact Except bubble you do not have to mark anything else in the section and the report will reflect that all 12 Cranial nerves are
103. here is an interruption of the spinolaminar junction line at the C4 segmental level The patient s cervical lordotj T cd ewadino soft tissues and lung apices ar al Impression 1 Straightened cervical lordotic curve Moderate disc space narrowing at C4 CS Anterior disc wedging at C4 C5 Instability with stress during flexion and extension at C4 C5 Anterior vertebral body listhesis at C4 Spinolaminar junction line disrupted at C4 Vertebral Bodies Normal Size Shape Lumbosacral Spine Radiographic Examination of the lumbosacral spine utilizing views taken in the A P and Lateral nroiections demonstrates the following The facet ioints annear svmmetrical and eaual Th Page 1062 Words 545 Enginh ws NOTE If you do not choose to select an order the report will appear similar to the one in Figure 7 below Figure 7 Report Radiographic 2 Impressions Not ordered C3 bi Ox gt Report Radiographic 2 2006 01 07 7 doc Compatibility Mode Microsoft Word DP 060520145613 Home Insert Page Layout References Mailings Review View Add Ins mj iz gt gt Ruale e CERI gt a ul Ea j Match Field Find Recipient Envelopes Labels Stet Mail Select taa Highlight Address Greeting Insert Merge Previe Finish amp Merge Recipients Re G Block paate Lade i utto Check for E is Create Start Mail Merge RADIOGRAPHIC REPORT Patient Mr Bob Jones Sex Age Male 55 Doctor Dr Kevin Mill
104. hing other than Primary or Secondary such as Co Morbidity You may choose further descriptors of your diagnosis to be listed on the report such as Acute Sub acute or Chronic or Mild Moderate or Severe In either case only one choice may be bubbled and the report would reflect the following for example 307 81 Tension Headache een Acute Severe ITE ness Treatments e Manual Therapies H1a Any combination of bubbles may be marked for the section Marking Myofascial Release Joint Mobilization or the Other bubbles will all generate a query that must be answered to complete the report e Physical Modalities H1b Any combination of bubbles may be marked for the section Marking Cryotherapy Diathermy Thermotherapy or Ultrasound with cause the system to display an automatic pick list of further descriptors that must chosen e Rehabilitation Recommendations In Office H1c This section is entirely query driven Anything bubbled will generate a Query asking for an input as to what rehabilitation you will be performing HZ ees Treatment Goals You may choose one or more answers The Other bubble supersedes anything else marked in the section TES eeesiers Visit Frequency In this section the From and To bubbles were added for ASHP users PRN
105. inflamed musculatures are evident specific to the right lower cervical spine Cervical ranges of motion are diminished with severe pain corresponding with clinical evaluation 97 To ensure the medical necessity of treatment Medicare requires that at least two of the four elements of PART be documented It is also required that one of those two be either the asymmetry misalignment or the range of motion abnormality Acceptable documentation of PART would include the A with P R or T or the R with the P A or T or just the A and the R but never just the P and the T If practitioners standardize their evaluation comparisons of treatment effectiveness and efficiency are possible PART is not meant to be a replacement for all joint evaluation procedures as there are testing procedures that are specific to a technique system leg check arm fossa test therapy localization etc Additionally visceral relationships should be considered as well as other testing procedures deemed necessary from data previously obtained This document is for informational purposes only and is not intended to be a conclusive outline of Medicare requirements For conclusive information please review the Medicare documentation guidelines for your state References http findarticles com p articles mi qa3841 is 199912 ai n8856567 pg 2 http www chiropub com issues articles 2006 02 06 asp 98 APP
106. intact However if you find all are normal with the exception of one or two you can also mark the Cranial Nerves Intact Except bubble and select up to TWO abnormal nerves e The Findings bubbles correspond with the Cranial Nerve numbers and all require query text to be entered CD LR Cerebellar Function 101 C4 C 5 C6 Gait The Normal bubble supersedes anything else marked in the section You may only mark ONE of the remaining choices Rapidly Alternating Movements You may mark both Left and Right Quickly and Accurately Normal for the test and supersedes any other bubbles marked Heel to Shin You may mark both Left and Right Quickly and Accurately Normal for the test and supersedes any other bubbles marked Romberg s Test You may only mark one choice for Negative or Positive Finger to Finger Smoothly and Easily Negative and normal You cannot mark Smoothly and Easily and Positive for the test Finger to Nose Smoothly and Easily Negative and normal You cannot mark Smoothly and Easily and Positive for the test Other 1 A Negative and Positive bubble is provided for you to add in your own tests Please see explanation of queries and predefined text for explanation Other 2 A Negative and Positive bubble is provi
107. ion Flexion is Moderately Restricted and Right Lateral Flexion is Severely Restricted Example Cerv Cmp FIx BkP Ext BiLgP ROM Flx MoRs RtLatFlx SrRs 7 Period Terminates a section Lumbosacral Spinal Exam 15 Bilateral Spasm Sacriliac Malpostiion straight Leg Raise On Right Back Pan at 40 egress Kemps To right Reveals Right Leg Pain Example LS SpnEx L5 BiSp Sac Mp SLR Rt BkP 40 Kmp Rt RtLgP 126 10 11 12 13 Exclamation Point Terminates a report Example Neuro DTR Bic Rt1 Lt Tri Rt3 Lt1 Plt RtAbs LtUpg Cerv Cmp Flx BkP Ext BiLgP ROM Flx MoRs RtLatFlx SrRs LS SpnEx L5 B1Sp Sac Mp SLR Rt BkP 40 Kmp Rt RtlgP Plus Sign Combines multiple findings of a test location Thoracic Spinal Exam T1 Right Spasm amp Right Tenderness and T2 Right Tenderness amp Malposition Example Thor SpnEx T1 RtSp RtTn T2 RtTn Mp Backslash Separates single right and left findings Neurological Assessment Plantar Response Right Absent and Left Upgoing Example Nur DTR Bic Rt1 Lt0 Tri Rt3 Ltl Plt RtAbs LtUpg Test Name Only Test is Positive Lumbosacral Lindner is Positive Minor s Sign is Positive Example LS Lnd Mnr Right Left Bilateral With Preceeding Name Test can be positive on either or both sides Lumbosacral Braggard Positive on Right Fabere Patrick Positive Bilaterally Right Flexed Antalgic Lean Example LS RtBrg BiFbP RtFIxA
108. iption File Name CPI In this screen you have the option to Rescan or Append the current document e If you choose Rescan you will receive a prompt asking if you want to delete the current record o If you choose Yes the record will be deleted and the Scan Document Images screen will appear so that you may Rescan the document o If you choose No you will be returned to the New Medical Record screen If you choose Append the Scan Document Images screen will appear so that you may scan additional pages for the selected document e If you choose Ignore you will remain in the New Medical Record screen Delete a Record Follow the steps below to delete an existing record 1 From the Main Menu click Generate Documents 2 Select a patient from the Pick Patient list 3 Once in the Generate Documents screen click Records The Print Medical Records Select Record File screen will appear See Figure 7 Pg 90 4 Select the record you wish to remove and click Delete at the bottom of the screen If you have further questions regarding scanning images and medical records using the Document Plus system please contact the training department at 800 642 0600 92 APPENDIX D P A R T for Medicare P PAIN A AS YMMETRY R RANGE OF MOTION T TEMP TONE TONICITY Using the acronym P A R T the five diagnostic criteria for spinal
109. itive may be marked Both Left and Right may be marked Additional bubbles may be marked to indicate where pain was produced during the test but if the Other bubble is marked it supersedes all other options and a query will be generated 104 e Stretch Tests D1d Shoulder Depression D1d1 Only one choice of Negative or Positive may be marked Both Left and Right may be marked Additional bubbles may be marked to indicate where pain was produced during the test but if the Other bubble is marked it supersedes all other options and a query will be generated o Soto Hall D1d2 Only one choice of Negative or Positive may be marked Both Left and Right may be marked Additional bubbles may be marked to indicate where pain was produced during the test but if the Other bubble is marked it supersedes all other options and a query will be generated e Distraction Tests Dle Cervical Distraction Bakody s Sign and O Donoghue s tests Only one choice of either Negative or Positive may be marked Both Left and Right may be marked Additional bubbles may be marked to indicate where pain was produced during the test but if the Other bubble is marked it supersedes all other options and a query will be generated In the case of these tests a Positive allevia
110. k Add and type glucosamine 5 Click Add and type multivitamins 6 Click Add and type chondroitin 7 Highlight chondroitin and use the Move Item in List up arrow to arrange it alphabetically at the beginning of the list 8 Click Close Save at the bottom of this screen We will customize another bubble on the Health Questionnaire form HQ3 1 Scroll down to find Pg 3 Section G Question Lh Are you allergic to any medications 2 Click the Yes bubble to select question Gih The Modify PreDefs screen appears Figure 30 below 35 Figure 30 Modify PreDefs G1 h e You Ever Been To A Chi b Do You Have A Family Ph Svala ess EP Dp ate dede ia i Ex am Ph SI clt a 4n Phoned i Have You Been Hospitaliz ec din The Past 22 E R son For Hospite liz atic Have You Ever Had Surgery S amp S ate Reason Results Of Surgery eens OHS G1H GTHEr Drug Allergies List Drugs Text Id List ti Move Item In List 3 codeine norphiry ve You Ever Had A Ser us Acci dent Injur Date amp Describe Inju Nita fork Relat ed ersonal ports In y Lr y ther re e rre ey ng Any hl monas Or Herb s I upple Hur o Text Id Edit aspirin Always Use Predetined Text Delete Report Location Close Cancel
111. ls from those physicians b Send narratives to Referred To physicians in advance c Send narratives to Referred From physicians thanking them for referrals 29 Generate a narrative for an Insurance company 1 In the Consultation Note section under Insurance select Initial 2 Make sure the insurance company associated with the selected patient appears in the field to the right of Insurance If not select the appropriate company from the drop down list 3 Click Generate under Controls 4 Your insurance narrative will generate automatically Notice that the query screens do not appear This 1s because you entered them when generating the previous narrative To make changes to query text refer to Pg 33 4 Generate a narrative for an Attorney NOTE The attorney report will be generated as a PAST TENSE document The query screens appear to insure that your document is grammatically correct 1 In the Consultation Note section under Attorney select Initial 2 Make sure that the attorney associated with the selected patient appears in the field to the right of Attorney If not select the appropriate name from the drop down list 3 Click Generate under Controls The Information Written on Form screen Figure 25 Pg 32 will appear 4 The text you entered previously appears in the Text hand written on form section
112. lso Procedural Notes reports pam thatradiates fromtheneckto the fingers on the nght side OBJECTIVE apy as called for by the examination outcomes are given to Mr Bob Jones My leg length measurement confirms the nght leg to be 1 8 of an inch short due to postural bre range of motion and resolve segmental dysfunction a light metered force a An evaluation of the cervical spme reveals the existence of subluxation coupled jarual adjustment are applied A light metered force adjustment is utilized on myvom asn located m the left upper range There are signs of joint dysfimction with 3 and C7 A mamal adjustment is used on C5 and C6 A light metered accompanying spastic inflamed and tender musculatures specific to the right upper cervical delivered to the right wrist The following modalities are administered to region which radiates Evidence of malposition is identified plus spastic deep paraspmal range for fifteen minutes Cryotherapy is employed to reduce local musculatures localized to the left middle cervical pine Joint dysfunction is evident together crease swelling To decrease pain and increase range of motion Myofascial asm inflammation and tendemess overlying the right middle cervical range ed In accordance with the cervical therapeutic exercise protocol outlined in Malaligament is apparent together with mmscular paan of the left lower Phim range tion utilized for the purpose of improving strength and restoring functional Subluxation
113. m and 1 Pg will automatically be selected Cover Letter When selected a cover letter addressed to the patient s insurance company will precede your daily note report 1 Pg If selected when generating multiple daily note reports each daily note report will begin on a separate page Sign Note Daily Note signature options are outlined below None No signature will appear at the end of your daily note report Attended This option is used when there is more than one doctor in the same office If selected the signature of the attending doctor doctor number bubbled on the form will appear at the end of the daily note report Signed By When selected the signature that appears in the Signed By field Lower right corner Figure 15 will override the doctor number bubbled on the form and appear at the end of the daily note report Signed By amp Footer The signature appearing in this area Lower left corner Figurel5 is the signature that will appear under the signature line at the end of your daily note reports and in the footer at the bottom of the page Figure 15 Generate Documents Daily Notes Select Visits screen Visit Order By Dates Ascending i Medicare V Cover Letter V Sign Note None Attended Signed By f Insurance Co All Cities PRIMARY amp Footer Yow Doctor D C Piscine Record EOF 37
114. muscles are evident specific to the right lower cervical spine which radiates Evidence of tenderness is identified in the right upper extremity This criterion may be identified on a sectional or segmental level through one or more of the following observation posture and gait analysis static palpation for misalignment of vertebral segments diagnostic imaging etc Documented on our DN FORM in the objective section PG 1 LEG LENGTH DEFICIENCY POSTURE and FORWARD FLEXION all show asymmetry or misalignment Figure 5 Objective section Leg Length Deficiency Posture Forward Flexion OBJECTIVE Onwarmd Flexion eU e o5 High Shoulder Lumodadr High Hip Pain gt ian limite Antalala MUSIC aaa a ao ange Of Motion Cervical DorsoLumbar 95 Figure 6 Objective section Daily Note report Sample Text OBJECTIVE The evaluation of the disparity in the length of the legs confirms the right leg to be 1 8 of an inch short reflective of postural compromise Analysis of his posture substantiates the head tilted to the right with forward flexion in the cervical spine Changes in active passive and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility Range of motion abnormalities may be identified through one or more of the following motion palpation observation stress diagnostic imaging range
115. n changes can only be made in Leg Length Deficiency and Range of Motion If you need to mark changes in an area other than the previous two you would NOT mark Same Assessment and would simply fill out the entire section again 18 In Leg Length Deficiency bubble R1 4 19 In Range of Motion Cervical area bubble Decreased and Moderate 20 In the Thrust Report section locate and bubble SAT Except at the top of the center column 21 In the column on the far right locate Occiput and bubble the N neutral or needs no adjustment this visit 22 In C2 bubble R right 23 In C4 bubble INF inferior NOTES a We took Occiput off our list by bubbling N added C4 and changed C2 b When SAT Except is bubbled changes can only be made to the Thrust Report NO changes can be made on the left side of the form under Today s TX General Listings If you need to make changes to Today s TX General Listings you would NOT bubble SAT Except and would simply mark ALL adjustments for that day 24 Mark Y for Patient Tolerated Procedure Well 25 Scan the form and generate the daily note report according to the guidelines on pages 56 57 26 You have completed the DN3c daily note form for Bob Jones second visit To print a travel card for Bob s third visit follo
116. n Forms Office Reports Document Plus Version 10 00 w kSta Server amp ctv You are now in the Pick Patient screen See Figure 2 below Figure 2 Pick Patient screen FA Doc umentPlus 9 010A4 Scan Images SCANIMAGE EXE WkSta ServerActv Pick Patient AIBICIDIEJFIGIH L J K LE M H O P OJ R S TIUJ VIW IX Y Setup tl Select Cancel 87 2 Select the name of the patient you are scanning images for You are now in the New Medical Record screen See Figure 3 below Figure 3 New Medical Record screen E r 2 i FA DocumentPlus 9 010A Scan Images SCANIMAGE EXE WkSta ServerActv E mx Mew Medical Record Patient Name Jones Bob ID it 3 Hedical Records On File Enter New Medical Record Description File H ame CPI 3 Enter the New Medical Record Name in the area provided at the bottom of the New Medical Record screen In Figure 3 above CPI Confidential Patient Information has been entered 4 Click Scan at the bottom of the screen 5 Scan the document make sure it is face up You are now in the Scan Image screen Your document now appears and you will notice that the New Medical Record Description entered in Step 3 above is shown at the top of your screen See Figure 4 below Figure 4 Scan Image screen F n FA DocumentPlus 9 010A Scan Images SCANIMAGE EXE WkSta ServerActv C
117. n Sees My Recent Documents 1 u RD IMAGE 1 JPG RD IMAGE 2 JPG RD IMAGE 3 JPG RD TMAGF 4 TPG RI DV DT Dowhletree RIDV DT Doubletree My Network Files of type Pictures gt File name 8 Select the desired image and click OK 120 You are now in the Locate RD Image Files screen The image should appear in the left portion of your screen Click the Select button in the lower left portion of your screen Figure 4 Locate RD Image Files screen r FA Doc umentPlus 9 010A Document Generation DOCUMENT EXE WkSta ServerActv Locate RD Image Files Patient Jones Bob 3 Exam Date ot 712 2012 View Image i Status I Clinical Evaluation Initial Final 11 03 24 9 Click Exit in the lower right portion of your screen Shown in Figure 4 above 10 Repeat steps 6 through 9 for each Region View you want in your report The Active Impressions Set Order and Modify Impressions screen will appear Shown in Figure 5 below Figure 5 Active Impressions Set Order and Modify Impressions screen r FA Doc umentPlus 9 010A Document Generation DOCUMENT EXE WkSta ServerActv Region Next Order Patient Name Patient Id Form Exam Date Cervical 2 Jones Bob Mr 3 RD2 154001 01 12 2012 Modify Impression Press Ctrl Tab To Return Grid Mild disc space narrowing at C2 C3 C3 C 4 t l Add
118. n are outlined below a To delete a form Click on the form you wish to remove Once highlighted click the Remove Form button Once the form is deleted it CANNOT be rescanned b To change CE3 to RE3 or RE3 to CE3 If you scan a Clinical RE Evaluation with Clinical Evaluation bubbled on the form click on the CE3 form you wish to modify and click the CE3 gt RE3 button This allows you to change the Clinical Eval to a Clinical Re Eval or a Clinical Re Eval to a Clinical Eval RE3 gt CE3 c To change HQ3 to HOR3 or HOR3 to HQ3 If you scan a Health Questionnaire RE Evaluation with Initial bubbled on the form click on the HQ3 form you wish to modify and click the HQ3 gt HQR3 button This allows you to change the Initial to a Re Eval or a Re Eval to an Initial HQR gt HQ3 Click Main Menu and proceed with Step 2 Scanning the Forms 22 STEP 2 SCANNING THE FORMS READ THIS PAGE BEFORE SCANNING Overview The next step is to scan the forms that you have prepared Listed below are some tips that will make scanning easy and prevent unnecessary errors Scanning Tips e Wait to scan forms until the screen reads Scanner Ready Feed Forms e The scanner will read both sides of the form at once e Make sure that the doctor number patient number and date fields are correct and right justified on the form For patient 3 you wo
119. n image of the Health Questionnaire 3 now appears on your screen Figure 28 below Figure 28 Modify PreDefs Image of Health Questionnaire Form E voc LULELLALELUSALEULS AUTUA MOONY Prevels MUDIFYPREDVEFS EAE WKS la gt er YEr ACI NU F sa SPEEL Z FOMI re Formms Report 4 1 2 gt 4 Bottom Top 4 Exit HEALTH QUESTIONNAIRE HISTORY AX EXTUZEXil dut E REVIEW OF SYSTEMS Are You Currently Suffe ring From Any Of The Symptoms Listed Below If This Is A Re Examination Mark Only New Symptoms Since YourLastExam lt gt No New Symptoms Since lt gt None Of The ister Your Last Ex am Listed E symptoms y low General F atigue aa okin Rash c VVealnes s c Redness c5 Fever continuous cc Skin Itching Loss OfSleep c Skin Dryness Chills co ntinu ous c VVeiaght C hange unplanned f Skin eze ma red inflamed skin lair lail Changes ruis e Easily hanges unplanned unplanned c leadaches il NZZINeESS Cough chronic Whe ezing chronic lt gt Difficulty Brea thing c Swollen Extre mities o gt Blue Extremities c Varcosities visible ve c Rapid Heart B eat lt Chest Pain alpitations c Heart Murmur 000 000 aintind gt E 5 Night Sweats J gt E Convulsions T em gt F gt Jerv ousn ess d T Depression prolonged lt gt Phobia
120. n the form in the space provided In the Assessment Diagnosis section a Bubble Prevs Unchanged and New Additional NOTE When Prevs Unchanged and New Additional are both bubbled the New Additional diagnoses are added in front of the old diagnoses on the travel card When only New Additional is bubbled the old diagnosis codes are removed and only the new code s will appear on the travel card The information will also appear in your daily note report 8 9 For Progress a Bubble Worsening In the Plan section a Bubble Per Initial Prev Plan 10 In the Today s Treatment Modalities section a Bubble Same Tx 70 11 For Rehab Therapy a Bubble Same Tx 12 Turn the form to Page 1 and locate the Objective section 13 In the Objective section a Bubble Same Assessment 14 In the Thrust Report Page 1 Right a Bubble SAT Except at the top of the center column 15 Bubble Y for the statement Patient Tolerated Procedure Well 16 Scan the DN3c form enter the queries and generate the daily note report according to the instructions on Pages 55 57 You have completed the Basic and Daily Note Travel Card tutorials If you have questions or need further assistance please contact the Document Plus Training Department at 800 642 0600 71 Section D Advanced Setup S
121. n will be NextAppointment 7 7 20 00 C associated with the TUE patient when Main Mena paom _ Mew rs AMomes Hem generating narratives B Patient c docplus3 01 ONdbf server patient dbf Record 2 2 5 Click the Pick button to the left of the word Doctor A list of In House doctors will appear Select the doctor from your office that will be treating this patient Click ok 6 Repeat for the Personal Physician Ben Casey and Patient s Attorney Harry Howe 7 Click Save then select the Insurance 1 tab at the top of your screen 19 NOTE You are now in the Primary Insurance Information screen See Figure 15 below Figure 15 Primary Insurance Information screen r FA DocumentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv Primary Insurance Information Jones Bob 3 e Information 1 Information 2 C insurance 1 7 Relation to Insured Primary Insured s Name Mr Bob O ees A Title First name Middle Last name Y Primary Insured s Address and Phone Street Apt YT Ciy Pompano Beach State FL ZipCode Primary Insurance Carriers Insured group _ Insured IDL Co Cairn Annual Max Visits 0 Insured c docplus9 010 dbfsserversinsured dbf Record Insurance 2 Accident Notes Social History Forms Self N None Sel
122. nd Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test o Goldwaith s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test Only one choice may be marked for either SI or Lumbar but not both o Trendelenberg s Test Both Left and Right may be marked Only one choice of either Negative or Positive may be marked e Root Tension Signs Stretch Tests D3d o Straight Leg Raise Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test There can be only one choice for degrees at which pain was produced 0 30 35 70 70 90 If the Other bubble is marked it supersedes all other options and a query will appear o Braggard s Test Both Left and Right may be marked Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test There can be only one choice for degrees at which pain was produced 0 30 35 70 70 90 If the Other bubble is marked it supersedes all other options and a query will be generated
123. nge when are they worse mark Morning c Fill in the Pain Diagrams similar to the way they were filled in on the last visit This tme document a decrease in pain intensity Bubble No New Aggravation Injury You would now have the patient sign and date the form in the Patient Signature and Date areas Go ahead and do this for Bob Jones In the Assessment section bubble Prevs Unchanged In Progress bubble Improving In Response to Tx In bubble 10 under Reduced Spasm Reduced Tenderness and Reduced Inflammation Bubble 20 under Increased Mobility and Increased Activities of Daily Living 66 13 Under Today s Treatment Modalities bubble Same Tx NOTE When you bubble Same Tx in Today s Treatment Modalities you can make NO changes in this section If a modality was added or omitted from the day s treatment you would NOT bubble Same Tx and would simply fill in the entire section again 14 In the Plan section bubble Per Initial Prev Plan since nothing has changed since we completed the visit schedule on the last visit 15 In Rehab Therapy bubble Same Tx 16 Turn the form to Page 1 and locate the Objective section 17 In the Objective section bubble Same Assessment NOTE When Same Assessment is bubbled in the Objective sectio
124. ning the Daily Note FOrmM essesessessescssoesoesoesoscoecoeccccccccesesseese JD Step 3 Generating the Daily Note Report cccccccccccccccccccssssssssssssses o D0 57 Before Printing the Travel Card esesccscsesececsesesecsoseseseceocceeeoesssseceessse se D OU Step 4 Printing Travel CAEUS oet oor Ver eEeRa FE REF ESIENIORUEE exe a reos sa s veis eeteieii D L 62 Customizing Travel Card Setup eceeesovesssoqesesessebsequeatoveseexseesevesseetesien 02 Understanding the Travel Card Part I 63 65 Step 5 Filling out the Daily Note Form Second Visit 66 67 Understanding the Travel Card Part II o 68 69 Step 6 Filling out the Daily Note Form Third Visit 70 71 Setin Y our TE BELONG NCE ona ind oty o PHA TESPUTADS QUO vu FIEL E Te Ib OVE rues Puis eoete s Ju SO Appendixes A J Appendix A Customizing the Daily Note DN3c Form 79 84 Appendix B Outcome Assessment Questionnaires ecce eee e eee e e eee eene 85 86 Appendix Scannitt MAn Q8 iuc cecidi ee pea erdt eco irasai Fe DE Order Deeds evo 87 92 Appendix D P A R T for MeulCatke sciccscsscecsnsssstncdssssxcscassatoccssasscnsanssnsndassasensassanss 93 98 Appendix E CE Version 3 Instructions escsscccccecececec
125. nl Spinal Exam with Midline Tenderness Cervical Spinal Exam C1 Midline Tenderness C2 Right and Midline Tenderness C3 Left and Midline Tenderness C4 Bilateral Tenderness Example Cerv SpnEx Cl MITn C2 Rt M1Tn C3 Lt M1Tn C4 BiTn Abbreviations The following sections will provide you with the abbreviations used throughout the travel card sections of the daily note form The designated abbreviations are industry average and are easily referenced to their intended meaning SECTION 1 Clinical Evaluation SECTION 2 Health Questionnaire Daily Note Complaints SECTION 3 Diagnoses SECTION 4 X ray SECTION 5 Therapy Modalities 127 Section 1 Clinical Evaluation Neurological Assessment Nuro Carotid Pulsations CP CP Right Rt finding Left Lt finding Bilateral Bi finding finding 011 CP RtO CP Rt0Lt1 CP Bil Bruit Brt Brt presentCarotid Car presentSubclavian Scl present Right Rt Left Lt Bilateral Bi Brt RtCat BiScl Craniocervical Functional Maneuver CFM Right Rt Left Lt Bilateral Bi CFM LtCFM Cranial Nerves CN CN CN I D CN II ID CN III AID CN IV IV CN V V CN VI VD CN VII VID CN VIII VIID CN IX TX CN X X CN XI XD CN XII XID CN 7IL XI Gait Gt Dystaxia Dys Gt DysGt Rapidly Alternating Movements RAM RAME Right Rt finding Left Lt finding Bilateral Bi finding finding Clumsily Clm Unable To Perform UTP
126. nnaire and a Clinical Evaluation are the minimum forms required to create a case in Document Plus Once a case is created you are able to generate Insurance Doctor and Attorney narratives In the Consultation Note section on the Generate Documents screen you will see three options under each heading Initial Re Eval and Final The Initial report will include your initial findings Re Eval will include your re evaluation findings Final will include Initial and Final findings Daily Notes are not included in narratives and must be generated separately c Refer to the table on Pg 37 for forms required to generate various reports Generate a narrative for a Personal physician 1 In the Consultation Note section under Doctor select Personal then check Initial 2 Click Generate under Controls The Information Written on Form screen Figure 25 Pg 32 will appear 3 Once you have entered the queries your personal physician s narrative 1s generated automatically 4 Notice that the information you typed appears in blue If you need to make changes to this text refer to Pg 33 4 5 Repeat the above steps to generate narratives for Referred To and Referred From physicians Practice Building Ideas a With your patients permission send narratives to their primary care physicians You will begin getting referra
127. o Cancel this Scan Session Press the Escape key or click the Cancel button NOTE Once the scanner initializes you will see a DocPlus Scanner Ready message in the upper right corner of your screen You are now ready to scan 24 2 Scan the forms that you have prepared HQ3 CE3 RD2 See Pg 23 for correct form orientation NOTES A Your form has scanned successfully when you see it listed in the Forms Scanned window Figure 22 below Figure 22 Forms Scanned r4 Document Plus Scan _ VX SCAN FORMS 01 1 2 2012 01 1 2 2012 3 Jones Bob 3 Jones Bob TTT BR 1 1 Generate Daily Note after scanning Each DN orm E I ravel Carc To Navigate the list Use Pagellpb key PageDown key Arrow keys or the Mouse To Cancel this Scan Session Press the Escape key or click the Cancel button B If you are getting a Validation WARNING Figure 23A below Press any key to stop the beeping Read the screen You may choose to Continue past these and fix them later or correct the form click Re scan and scan the form s again Figure 23A Validation WARNING r4 Document Plus Scan _VX SCAN FORMS A scanned Form is being processed Please wait Scanned Forms Validation WARNING Form Health Questionnaire 3a Id HO3a Sht 1 Serial 422194 Patient Jones Bob Mr Visit Date 01 12 2012 Use the Vertical Scroll Bar MEE ALAALALAtGLA
128. o be completed by the patient e Symptom Survey This form must be used in conjunction with Symptom Survey Maestro Software If you are interested in using this form and do not have Symptom Survey Maestro you can contact them at 585 924 4456 or go to their website www surveymaestro com Section A Initial Setup After the installation and before you start using the system complete the steps below 1 From the Main Menu click Set up You are now in the Setup Information screen Settings tab Figure 1 below Complete the following steps to customize the Settings screen Figure 1 Setup Information screen Settings tab F 4 Document Plus Version 10 00 Miscellaneous MISC EXE WkSta ServerActv Setup Information f Settings Daily Notes 1 Daily Notes 2 Consult Notes Miscellaneous 1 Miscellaneous 2 Practice Name City State County USA z Scanner pP vx F Por F Baud Rate Light Dark 015 Word Processor Microsoft Word Global Documents Path C DP_DATA_ PATIENT LETTERS Not Shared Not Global MANAGEMENT Software None IF Empty Time Ou Acknowledge New v Modify v Delete MW Setup DBC Appt V Proper Insured Query PM Data Path EEUU Export Mode Noe Software Non File CHARGES IMP Service Export Path EEUU Document Actions Layout Letter Layout Report Save Cancel Wi Pmsware c docplus8 010 sdbPspm pmswa
129. ocuments simultaneously by selecting multiple documents before you click Generate Clear Clears ALL selected documents Forms View active and inactive forms or edit the date on forms scanned for the selected patient Patients Allows you to select a different patient with forms on file from your patient database Records View edit and print scanned images for the selected patient Main Menu Return to the Main Menu Query Edit When selected this feature allows you to edit previously entered query information Dates Administered When selected the system will select the proper Outcome Assessment forms associated with the selected patient s case 31 QUERIES Overview When specific information cannot be indicated with existing bubbles it must be hand written onto the form There are several areas on each form where additional information can be written When the bubble associated with one of these areas is bubbled and the form is scanned the Information Written on Form or Query screen appears Figure 25 below The hand written information is entered into the system using these query screens A COMPLETING THE QUERY SCREENS 1 Locate the origin of the query In the Information Written on Form screen the upper portion of the window contains a description of where on the form the question originated from i e the form type the page number and location see Figure 25 below Find
130. of dates or a specific patient o After selecting Billable Charges by date you can check the Assessment box to include a list of initial diagnosis codes for each patient appearing in your report o If New Injury has been marked on a daily note form this report will list the date the New Injury was indicated o When a New Injury is indicated the report will print the text Update Box 14 This is to serve as a reminder to update the appropriate field on your HCFA form e Birthday List This feature enables you to generate a list of patient birthdays for a specific month O If Deceased is checked in the patient database Information 1 screen the patient will not appear in the birthday list e Clinician Information This feature enables you to generate a list of contact information for doctors In house personal referred to and referred from and attorneys in your databases 114 Figure 2 Edit Patients Batch Daily Notes screen FA DocumentPlus 9 010B Batch Daily Notes DN_RPT EXE WkSta ServerActv Edit Patients Batch Daily Notes Alexander William Anderson Charles nderson Christie Asbill Capers Asbill Patsy Atria Joshua Auerhamer Nichole anks Robert Wyman artley George Session Print List Main Menu Id Number From Date To Date 2215 01 06 2002 01 06 2012 11257 01 03 2012 01 03 2012 37165 01 03 2012 01 06 2012 al Order B
131. on will appear in your daily note report Examples are outlined below Example of what you might enter for Other Text ID Exercise program Predefined Text To improve circulation and decrease joint stiffness it is recommended that the patient participate in some form of aerobic exercise 3 times per week 81 Addt l Diagnostic Testing Use this bubble to document a recommendation for additional diagnostic testing Examples are outlined below Example of text as it appears in the daily note report is warranted for the patient Examples of what you might enter to complete the above statement 4n MRI A CAT scan Exercise Home Care Instructions Use this bubble when prescribing home care exercise You can create a pick list of home care exercise protocols Examples are outlined below Example of text as it appears in the daily note report The home care procedure now includes 7 Examples of what you might enter to complete the above statement doorway stretches strengthening exercises for the rhomboids Other Home Care Instructions Use this bubble when entering additional home care instructions for items not listed on the daily note form Examples are outlined below Example of text as it appears in the daily note report The home care procedure now includes E Examples of what you might enter to complete the above statement rest for
132. ooococccccecececeseseseeeeeeeooe 26 Step 3 Generating DOCUImellls iiiiessseses yat kee ee prO RE E ER tecdseusaceetessicceeensntess 27 31 Orei RTTTEETETTR m 27 PC RS SUMAT IES 51 xcars QTIOD IL D LT A EEES 28 Consultation NOl ssorisrssriori e distr kireno r EFE AV RR OFT PEERS TE ENERIRR TREE UE 29 30 Patent UNOS E E E E E E E E E A EE 30 31 COTON e E E aaa a aaa OL lcu c 55 E E E A E E E E 32 36 Completing the Query Screens ccccccccceccccccccccccceccccscsscsscsssssseseesdID IS Customizing QuUeries esessesecsececsecocsecceseceseseooeoecossssssssseesesee oes ee J9 IJ Reports Required EOEHIS o soccccaaacass ocecesasaneesusaynenacetaenaunennaesaencescenentensssevee 37 Step 1 Filling out the Daily Note DN3c form eeeeeeeeeee eee eee 0 24 Date DR Patient Number cceeeeeeeeee eee ee esecosocscsscsess sooo ce D SVIBDIOIBS SECON Moc cca cce orbit oe TREE Oe sana DeuUvEoI anaa auus Symptoms Section II sesessesessesecsesoeoesoeseeoescsossssseseees e eef L 42 E a A E E E A A 43 DDO r E E E E E EE E E 43 EAE E E E A E OE 43 Today s Treatment Modalities ossessesessesesoeseeoeooecccosssssssssseseeoe see FD EEL N E A T E UTRAM 46 WET E EE A E eer ere 47 48 Toda s Tao General LINES vost creat ereecutnenaminnaies sonar TETTE SOAPT Of Additional INO IE oiu rEEE PI PP PRADERE MES peEPY ECCE UE ID IIE Esci 4 Step 2 Scan
133. or Hundreds Tens and Units A6 Respiration Rate Choose one bubble per line for Tens and Units A7 Blood Pressure e Choose the position in which the pressure was obtained Seated Standing Supine e Use either Left or Right but not both e Bubbles must be filled in for both Systolic and Diastolic e Mark only one bubble per line for Hundreds Tens and Units A8 AT6 For questions A8 A16 choose either the Normal Finding or Abnormal WNL Within Normal Limits Abnormal findings if bubbled will generate a query ATI sts Peripheral Circulation A172 Arterial Pulses e Both right and left must be marked For reference O absent 1 diminished 2 normal 3 full 4 bounding A17b Lower Extremity Venous e Choose either WNL or any of the other objective finding choices but not both e The Other bubble if marked supersedes all the other bubbles ge db auos Of Additional Note You can enter information for these nine bubbles each time you want to add additional information or you can predefine lists of customized entries to choose from OAD iens Medical Records You can enter information for these nine bubbles each time you want to add additional information or you can predefine lists of customized entries to choose from SECTION B
134. or Dr Ben Casey as shown below in Figure 6 Figure 6 Doctor Information screen Personal Physician r FA DocumentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv Doctor Information Dr Ben Casey M D PER Information 1 Information 2 Name Type ID Number PMRet Title First name Middle Last name Credentials Dr Ben Casey 1 1 E Letter Greeting Dr Case Practice Medical Physician s Clinic Attention Ben Casey M D Address Phone Numbers Street 7984 Scenic Hwy Office 1 813 445 6598 Suite J1 Oficez C City 34589 Fax 813 445 5698 State Zip Code Home E Mail Mom omowe vem Record 2 2 i 10 53 56 14 4 Click Save then click the Pick Doctor button NOTE You are now at the Pick Doctor screen where all doctors are listed See Figure 7 below Figure 7 Pick Doctor screen r Ckidno c sdocplusS 010 dbfsserversckidno dbf Record 4 6 5 Notice that Ben Casey M D is now listed in the doctor database and that he is categorized as a personal physician PER 6 Click the Attorney button to access the Attorney database 15 NOTE You are now in the Pick Attorney screen You currently have no attorneys listed here Figure 8 Pick Attorney screen r FA Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActy Pick Attor
135. ormation entered here will appear in the Plan section of your daily note report and be preceded by The following was prescribed or followed by was prescribed Examples are outlined below Example of text as it appears in the daily note report Multiple items bubbled The following were prescribed this session Single item bubbled This session was prescribed 23 66 Examples of what you might enter to complete the above statement a multivitamin a calcium supplement a TENS unit At the bottom of the X Rays section you will find a bubble with an empty line beside it You may create a pick list of any x ray views not listed on the form When predefining this bubble the new item should be entered into the Text ID box For this area it is not necessary to enter information into the Predefined Text box Example of text as it appears in the daily note report A x ray was taken today Examples of what you might enter to complete the above statement knee AP Lat hip Lat view You will notice that there is a Technique Bar located in each treatment section on page 1 In the Thrust Report the technique bar is located slightly to the left of the TMJ listing box Under Today s Tx General Listings you will find one for the Tx1 section one for the Tx2 section one for the Upper Extremity column and one for the Lower Extremity column
136. ory Deficit SenDef SenDef Cl finding T1 finding L1 finding SS finding finding Right RO Hypo Hyo Hyper Hyp Left LO Hypo Hyo Hyper Hyp SenDef C3 RtHyo T8 LtHyp L3 RtHypLtHyo Plantar Response PIt Plt Right Rt finding Left Lt finding Bilateral Bi finding finding Absent Abs Upgoing Upg Plt RtAbsLtUpg Plt BiUpg Cervical Region Orthopedic and Spinal Examination Cerv Spinal Examination SpnEx SpnEx Occ finding C7 finding finding Right Rt Left Lt Bilateral Bi Spasm Sp Right Rt Left Lt Bilateral Bi Midline MI Tenderness Tn Articular Fixation AF Malposition Mp SpnEx C1 BiSp C2 RtSp BiMITn C3 RtSp AF Mp C4 RtMITn Compression Test Cmp Cmp Neutral Nt finding Flexion Flx finding Extension Ext finding Right Lateral Flexion RtLatFIx finding Left Lateral Flexion LtLatFIx finding finding 4 Neck Pain NKP 129 Right Upper Extremity Pain RtUEP Left Upper Extremity Pain LtUEP Bilateral Upper Extremity Pain BIUEP Cmp Nt FIx NkP Ext RtUEP RtLatFIx NkP BiUEP Valsalva Val Val Distraction Dst Dst Range Of Motion ROM ROM Flexion FIx finding Extension Ext finding Right Lateral Flexion RtLatFIx finding Left Lateral Flexion LtLatFIx finding Right Rotation RtRot finding Left Rotation LtRot finding finding Mildly Restricted MiRs Moderately Restricted MoRs Severly Restric
137. oulder Rt Lt Shdr Right Left Arm Rt Lt Arm Right Left Elbow Rt Lt EIb Right Left Fore Arm Rt Lt FA rm Right Left Wrist Rt Lt Wrt Right Left Hand Rt Lt Hnd Right Left Rib Rt Lt Rib Right Left Buttock Rt Lt But Right Left Hip Rt Lt Hip Right Left Thigh Rt Lt The Right Left Leg Rt Lt Leg Right Left Knee Rt Lt Kne Right Left Ankle Rt Lt Ank Right Left Foot Rt Lt Ft complaints Symptoms c characteristics 1 gt intensity gt frequency s gt Status 132 symptoms Pain P Numbness Nmb Tingling Tng Stiffness Stf Soreness Sor Weakness Wek Swelling Swl characteristics Burning Brn Dull DII Sharp Shp Shooting Sht Stinging Stg Throbbing Thb intensity Mild Mi Moderate Mo Severe Sr frequency Occasional Oc Intermittent In Frequent Fr Constant Cn Status Improving Im Worsening Wo Unchanged Un Resolved Rs From HQ initial cmplts BiNk P RtUBk P Sor RtShdr P Nmb Tng Stf From DN current cmplts BiNk P 155r f gt Cn s gt Wo RtUBk P Sor c gt Brn 1i Mo f gt Fr gt Uc RtShdr P Nmb Tng Stf c gt Shp Sht Stg 1 gt M1 f2Oc s gt Im Section 3 Diagnoses Code Abbreviation Description 353 0 Thor Outlet Syn Thoracic Outlet Syndrome 524 6 TMJ Syn Temporomandi
138. our travel card You may also enter additional travel card information for a patient via the patient database See instructions below Entering information for the SOAPT 2 bubbles via the Patient database 1 From the Main Menu click Databases You are now in the patient database 2 Select the patient for whom you want to enter information double click or highlight and select the patient name 3 Locate and click on the Notes tab at the top of the screen 4 Enter information into the appropriate section s With the exception of DN Diagnosis Codes in the Patient database Notes screen ALL of the SOAPT 2 information regardless of method of entry appears in the Notes section on your printed travel card If you have questions or need additional assistance with customizing the daily note form please call the Document Plus training department at 800 642 0600 84 APPENDIX B Outcome Assessment Questionnaires The healthcare and legal systems of today are moving into an era of assessment and accountability The emerging tools for measuring the effectiveness of patient treatment procedures are the Outcome Assessment questionnaires which offer a statement of both subjective and objective data These questionnaires are available for your patients to fill out and provide you and your staff with assessment tools that can help establish validity responsiveness and reliability of treatment
139. port training and scanner warranty information Computer requirements Preparation for installation of your software Forms Ordering Information and form descriptions Section A Initial Setup e Step by step instructions for the Setup Settings screen Section B Document Plus Tutorial I Basic e Comprehensive tutorial takes you through a basic insurance case from start to finish e Enter information into Doctor Attorney Insurance and Patient databases e Scan forms e Generate summary reports and comprehensive narratives Section C Document Plus Tutorial II Daily Note Travel Card e Step by Step guide to completing the daily note form DN3c e Using Same As bubbles DN3 form e Printing and Understanding the travel card Section D Advanced Setup Setting Your Preferences e Detailed outline of the Setup screens Appendixes A J e Additional helpful information with various program features forms and guidelines For Further Help Document Plus provides technical assistance as well as scheduled telephone training sessions If you need assistance with the software or the scanner please call our technical support department at 800 642 0600 Document Plus Support The Document Plus software is sold with 90 days of unlimited technical support and training via telephone Following the 90 day period annual support contracts are available The annual support contract includes unlimited technical suppo
140. produced o Beevor s Sign Only one choice of Negative or Positive may be marked Additional bubbles may be marked to indicate where pain was produced during the test There can be only one choice for Superior Movement or Inferior Movement e Stretch Test D2d o Shepelmann s Sign Only one choice of Negative or Positive may be marked Both Left and Right may be marked Additional bubbles may be marked to indicate where pain was produced during the test There can be only one choice of either Concave or Convex e Other 1 D2e Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text e Other 2 D2f Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text e Other 3 D2g Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text e Of Additional Note D2h You can enter information for these thirteen bubbles each time you want to add additional information or you can predefine lists of customized entries to choose from TDS es Lumbar Spine e Range of Motion D3a If you mark Normal In All Positions Except you do not have to mark anything else
141. pty Form Warning Beep Continuous Patients Ordered By Screen Size Normal Height 550 E Width System ID Product Code CD 4 4 Document Actions Layout Letter Layout Heport Save Cancel Pmsware c docplusS 010 dbfspm pmsware dbf Record EOF 11 Record Unlock Complete the following steps to customize the Miscellaneous 1 screen 1 Type of Practice If you choose multidiscipline practice this feature is irreversible Please call our technical staff for assistance with this section 76 2 Limited Patient Months 12 This field represents a value of time in this case 12 months If a patient has been entered into your database and has zero scanned forms on file they are considered a limited patient You can leave the default values or change them They are indexed when it is time to purge the database Inactive Patient Months 24 This field also represents a value of time in this case 24 months If a patient has completed treatment and no activity is recorded through scanned forms they are considered inactive patients You can keep the default settings or change it to suit your practice 3 Purge Log Days After the number of days shown you cannot recover any records previously deleted Back up Days The system will ask you to back up after 7 days You must back up every 14 days 4 Install Mode Work Station and Server Path This information is pulled automatically from the in
142. r Information 1 Information 2 Insurance PAccident Notes Social History Forms Secondary Insurance Secondary Insured s Name Title First name Middle Last name Secondary Insured s Address and Phone Street Home Phone Cd DF fice Prones ST Cw CL See Zip Code _ Secondary Insurance Carriers Company Save Main Menu potion New Land A Insurance T Patient c sdocplusS 010 dbfsserverspatient dbf Record 2 2 NOTE You will only be using this screen when you are billing a secondary insurance company For this tutorial we will not be entering any information in this screen 1 Select the Social History tab at the top of your screen NOTE You are now in the Social History Information screen See Figure 17 below Figure 17 Social History Information screen FA Doc umentPlus 9 010A Database Maintenance DBMAN EXE WkSta ServerActv Social History Information Jones Bob 3 Information 1 Information 2 Insurance 1 Insurance 2 Accident Notes Social History mployer Spouse Name Smkes k ae CLADGRE aee n Bottes Beo nein Sese Lives With eras City Pompano Beach FI 56984 Alone Spouse Caffeine State Zip Parents Children 0 Drugs sor salesman o 1 Ohe 3 ob Entails Description Bon 0 1 pouse Employer Address Education bl G a i E Secondary Grade ii Ll Zip College Years Other
143. r on your keyboard and continue with Generating Documents Pg 27 26 STEP 3 GENERATING DOCUMENTS Overview e Reports The summaries listed in this group with the exception of Daily Notes and HMO Forms are designed for in office use e Patient Letters These documents are excellent practice building tools see Pg 30 31 The Initial Report Of Findings document is usually given to the patient on their report of findings visit The Welcome to the practice letter can be customized Thank You letters may also be generated e Consultation Note This is where you generate narratives for Doctors Insurance Companies and Attorneys Also see practice building ideas on Pg 29 e Controls This section enables you to navigate within the program from the Generate Documents screen Functions of each button are outlined on Pg 31 Figure 24 Generate Documents r FA Doc umentPlus 9 010A Document Generation DOCUMENT EXE WkSta ServerActv Generate Documents Jones Bob 3 Initia PRA History Clinical Evaluation X Ray Summary Report Clinical Re E valuation IF Accident Injury History Automobile Accident I Daily Notes Outcome Measures HMO Forms Abbreviated Report Signed By Form Current Patient Letters B Welcome To Practice Initial Report Of Findings Consultation Note 3 army sq Attorney Howe H
144. rative Changes Narrowed Dis Spacing NDS NDS C7 T1 T11 T12 NDS T1 T2 T2 T3 T3 T4 Posterior Spurring PsSp PsSp C7 T1 T11 T12 PsSp T2 T3 T3 T4 TA T5 Anterior Spurring AnSp AnSpzC7 TIl T11 T12 AnSp T4 T5 Right Foraminal Encroachment RtFoEn RtFoEn C7 T1 T11 T12 RtFoEn T2 T3 T3 T4 TA T5 Left Foraminal Encroachment LtFoEn LtFoEn C7 T1 T11 T12 LtFoEn T2 T3 T3 T4 TA T5 Scoliosis Scs Scs Right Rt Left Lt Mild Mi Moderate Mo Severe Sr T1 TI T2 T11 T121T12 Scs RtMo T6 T7 Scs LtMi 136 Lumbosacral Spine Evaluation LS Generalized Osteoporosis GOp Mild Mi Moderate Mo Severe Sr GOp SrGOp Lytic Blastic Changes L B L B Degenerative Changes Narrowed Dis Spacing NDS NDS T12 L1 L5 SI NDS T12 L1 L1 L2 L2 L3 Posterior Spurring PsSp PsSp T12 L1 L5 S1 PsSp L2 L3 L3 L4 L4 L5 Anterior Spurring AnSp AnSp T12 L1 L5 S1 AnsSp L5 S 1 Right Foraminal Encroachment RtFoEn RtFoEn T12 L1 L5 S1 RtFoEn L2 L3 L3 L4 LA L5 Left Foraminal Encroachment LtFoEn LtFoEn T12 L1 L5 SI LtFoEn L2 L3 L3 LA L4 L5 Scoliosis Ses Scs Right Rt Left Lt Mild Mi Moderate Mo Severe Sr LI LI L2 L5 S1 I S1 Scs LtMi L1 L2 Scs Rt L2 Antalgic Lean AnL Right Rt Left Lt Flexion Flx AnL RtFIxAnL 137 Spondylolisthesis Spls Spls L5 Other Spondylitic Spe
145. re 23 Pg 69 68 Figure 23 Travel Card Thrust Report INF Occiput Atlas Hu merus Scapula j LI INF 69 We will now use the form with the printed travel card information for Bob Jones third visit The purpose of this part of the tutorial is so that you can gain an understanding of how to document a new injury and add additional diagnoses to the daily note form DN3c l 2 Bubble today s date in the date columns in the upper right corner on Page 1 The 1 should be bubbled under DR and the 3 should be bubbled under Patient Number If the pre printed black squares do not line up you will need to adjust the calibration settings before going any further Please contact our technical support department at 800 642 0600 for assistance Turn the form to Page 2 and begin with the Symptoms section Fill in the bubble next to If your symptoms have not changed since your last visit indicate here at the top of Page 2 On the RIGHT SIDE Low Back area a In the first column bubble Pain Stiffness and Soreness In Symptoms Section II a Bubble 8 in the pain scale If your symptoms change when are they worse mark Morning c Fill in the Pain Diagrams similar to the way they were filled in on the last visit This time document a decrease in pain intensity d Bubble New Injury and write pulled low back o
146. re dbf Record EOF 11 Record Unlock 10 34 48 2 Verify your city and state 3 Enter your practice name This is the name that will appear as the footer on your reports 4 Select the scanner type DocPlus Only applies to the computer where the scanner is connected You will see a YES NO option for enabling the pain diagram If you select YES the pain diagram DN3 Pg 2 section 2 will appear with the patient signature and date in your generated daily note report See Figure 3B Page 42 and Figure 16 Page 57 If you select NO it will not appear in the report 5 To select the word processor click on the pull down arrow and select Microsoft Word NOTE Once the version is displayed click Save 6 PRACTICE MANAGEMENT Please call our technical support department for help setting up your billing software interface See Pg 8 to view current interface partners NOTE Additional options located within the Advanced Setup screens can be found on Pages 72 78 Many of those options are related to customizing user preferences for reports and narratives It 1s recommended that you complete the step by step tutorial before customizing the Advanced Setup screens 10 Section B Document Plus Tutorial I Basic USING DOCUMENT PLUS Introduction This step by step tutorial will give you a working knowledge of the Document Plus system by taking you through a test case
147. re used for other areas e DeGowin amp DeGowin s Diagnostic Examination e Mazion s Illustrated Reference manual of Othro Neuro Physio Clinical Diagnostic Techniques e Cipriano s Photographic Manual of Regional Orthopaedic and Neurological Tests e Hoppenfeld s Physical Examinaion of the Spine amp Extremities e Mosby s Guide to Physical Examination e Ombregt Bisschop Veer and Van de Velde s A System of Orhopaedi Medicine e AMA Guides to Guides to Evaluation and Permanent Impairment 5th Edition 113 APPENDIX F List Functions In the upper right corner of the Main Menu you will notice a button labeled List This section outlines the available functions of the List feature Follow the instructions below to access the List feature 1 From the Main Menu click List The Available Lists screen will appear Shown below in Figure 1 Figure 1 Available Lists screen r I FA DocumentPlus 9 010A Lists REPORT EXE WkSta ServerActv Available Lists Billable Charges Birthday List Clinician Information Daily Notes Edit Batch Session Daily Notes Generate Batch Forms Scanned Insurance Companies New Patients Patient Carrier Patient Consultation Patient List Functions of each item in the Available Lists screen above are outlined below e Billable Charges This feature enables you to preview or print a copy of all billable charges for a specific date a range
148. rev Plan Per Initial Prev Plan Changed As Follows When both of these are bubbled simultaneously Changed As Follows will appear in your notes as a modification to the current treatment plan Additional Recommendations Use this section if you wish to document additional recommendations for further examination Home Care Instructions Use this section when you wish to recommend additional home care Visit Schedule Use this section to document a patient s visit schedule You may only bubble one item in the first row Daily Weekly Monthly PRN PRN can be user defined When it is bubbled a query screen will appear The Visits this Plan section is used to document the total number of visits in the current treatment plan Exam When using this section you must bubble the status of the patient 1 e new patient established patient and choose what level of examination was done This section is used primarily when transferring charges to interfaced billing software The information recorded here will also appear in your daily note report 15 You want to see Bob 3 times per week for 4 weeks a total of 12 visits Under Visit Schedule bubble the 3 next to Weekly Then to the right of Visits This Plan bubble the 10 and the 2 12 visits shown below in Figure 6 16 Under Home Care Instructions bubble Rest and Ic
149. rint Medical Records Select Record File screen Shown in Figure 7 Figure 7 Print Medical Records Select Record File screen r FA DocumentPlus 9 0104 Document Generation DOCUMENT EXE WkSta ServerActy E 6 Print Medical Records Select Record File Patient Name Jones Bob Idi 3 Medical Records On File CPII 2102701712 16 26 52 Delete Cancel 90 4 Select CPTI from the available list See Figure 7 Pg 90 You are now in the Print Medical Records screen Figure 8 Print Medical Records screen FA Doc umentPlus 9 010A Document Generation DOCUMENT EXE WkSta ServerActv Print Medical Records Jones Bob 3 CPI Page 1 of 2 CONFIDENTIAL PATIENT INFORMATION DATE PLEASE PRINT PATIENT INFORMATION Next Page FULL NAME DATE OF enr D 5 52 AGE me Fo ADORESS APT Flip Q city Otlanta STAT zie cove 30022 Home PHONE 10 4i ALTERNATE PHONE GELL EMAIL ADDRESS EMPLOYER S NAME OCCUPATI Change Document WORK ADDRESS cim STAT ZIP canus WORK PH a70 SSs Ie Jbex DATE SYMPTOMS BEGAN Egit MARITAL STATUS SINGLE MARRIED WIDOWED O HOW DID YOU HEAR ABOUT US EMERGENCY CONTACT PHONE CLAIM INF ION IS YOUR CONDITION DUE TO AN AUTO ACCIDENT O APERSONAL INJURY 1 AWORKINJURY L OTHER O TYPE OF CLAIM CASH J GROUP HEALTH INS O PERSONALINJURY O WORKER S COMPO MEDICARE O IWILL BE PAYING TODAY BY CASHL CHECK J vi
150. ripheral Joints Elbow Sprain Strain Peripheral Joints Knee Sprain Strain Peripheral Joints Ankle Sprain Strain Peripheral Joints Patellofemoral Dysfunction Cervical Other 1 Cervical Other 2 Thoracic Other 1 Thoracic Other 2 Lumbosacral Other 1 Lumbosacral Other 2 Pelvic Other Perpipheral Joints Other 1 Perpipheral Joints Other 2 134 Section 4 X Ray Cervical Spine Evaluation Cerv Generalized Osteoporosis GOp Mild Mi Moderate Mo Severe Sr GOp MiGOp Lytic Blastic Changes L B L B Degenerative Changes Narrowed Dis Spacing NDS NDS C1 C2 C6 C7 NDS C1 C2 C2 C3 C3 C4 Posterior Spurring PsSp PsSp Occ C1 C6 C7 PsSp C2 C3 C3 C4 C4 C5 Anterior Spurring AnSp AnSp Occ Cl1 C6 C7 AnSp C4 C5 Right Foraminal Encroachment RtFoEn RtFoEn Occ Cl C6 C7 RtFoEn C2 C3 C3 C4 C4 C5 Left Foraminal Encroachment LtFoEn LtFoEn Occ Cl C6 C7 LtFoEn C2 C3 C3 C4 C4 C5 Scoliosis Scs Scs Right Rt Left Lt Mild Mi Moderate Mo Severe Sr C2 C2 C3 C6 C7 C7 Scs RtSr C6 C7 Scs Rt Antalgic Lean AnL Right Rt Left Lt Flexion Flx AnL RtFIxAnL 135 Normal Curve To The Anterior NCAn Well Maintained WM Straightened St Reduced Rd Reversed Rv NCAn WMNCAn Thoracic Spine Evaluation Thor Generalized Osteoporosis GOp Mild Mi Moderate Mo Severe Sr GOp MoGOp Lytic Blastic Changes L B L B Degene
151. rrent daily note DN 14 Include CoPay If selected the CoPay information you have put in the Insurance 1 screen in the patient database will print on the daily note travel card in the Notes section 15 SOAPT2 You may choose to record additional information by using the SOAPT2 bubbles on the daily note form DN3c By default Travel Card is selected This means that information entered using the SOAPT2 bubbles should be short and abbreviated and will appear ONLY on the travel card If Note is chosen the bubbles will function similar to the SOAPT1 bubbles and appear ONLY in the daily note report 16 Default Treatment Billing If you are using the DN3 or DN4 forms you may select a default attended unattended time for modalities without actually marking it on the form 17 Batch When generating daily notes by batch you can select all patients to print out in one document or print a separate document for each patient What you select here will be your default settings 18 Layout If Cover Letter is selected a cover letter will appear each time daily notes are generated If One Per Page is selected each daily note will begin on a new page 19 Sign Note If None is selected no default signature will appear Select Attended and the signature of the doctor bubbled on the form will be added to the daily note If Signed By is selected you will be able to select the signature from a list of
152. rt training and software upgrades Should you choose not to take advantage of the annual contract we are happy to provide technical support and training at an hourly rate Software upgrades will be available at an additional charge You will be notified by mail when your 90 day free support expires This notification will include the current yearly support rate Please call us at 800 642 0600 should you have any further questions Training is available by telephone To schedule session s call 800 642 0600 We also offer virtual telephone training for customers with internet access IN PREPARATION FOR TRAINING e Be sure your software and scanner are installed and have been verified by our technical support department e Download and print the Bob Jones Sample Case and complete your forms according to the instructions e Plan for a minimum of 1 to 2 hours of uninterrupted time to complete each session Technical Support is available by telephone Call 800 642 0600 to install Document Plus Scanner Warranty For a period of one year from date of purchase any damage due to defective material or workmanship will be repaired at no charge Note that abusive wear and tear or damage caused by accident disaster misuse unauthorized modifications and unauthorized service is not covered In such cases charges are at the discretion of Document Plus Technology Inc An extended warranty is available Contact a Document Plus representa
153. s excessive fears lt gt Memory Loss Orlmpairment Mood Swings excessive Left Right Hearing T rouble Ringing in Ears Pain in Ears Ear Disch arge Vision Trouble Pain in E ves Eve Discharge Nose Sinus Pain gt Decreased Ap petite lt gt Incre ased Appetite cc Abdo minal Pain lt gt Hemorrhoids Excess Gas gt Vomiting excessive Diam nea excessive Constipation excessiv e gt HeartburndAndigestion u U 100 cessive Drainage c Painful Urination c Inability To Hold Unne lt gt Frequent Urin ation lt gt Urinary Retention c Bed wetting c Imeg ular Menstruation lt gt Painful Menstruation c Abnormal Vaginal Blee dini amp Steri lity c ose Bleeds chro nic lt gt Nasal Infections chronic a gt Absence Of Smell lt gt Mouth Sores lt gt Bleeding Gums Enlarged Glands Of Taste lt gt Abnormal Taste Sensation Tonsillitis Infected Tonsils lt gt Absence c l at Are Your Current Habits pa Smoking Gila Never lt 1 1 gt L gt a Caffeinated Drinks cC GI Never lt 1 1 Alcohol Consumption Never za 1 Drug Substance Abuse Ne Yes If Yes Discuss With Doctor Days P er Week zi Ue 28 Exercise Maar Kinds Of Exercise You Do gt Wa Iking lt gt Jogging lt gt Golf c Tennis Other G MEDICAL HISTO RY 1 HEALTH CARE a Have You Ever Be en To A Chiropractor 5
154. s screen Defaults Form Id ersion RevLtr TERME Change defaults for the way your patient list is sorted in the Print Scanned Pending Order By Name Printer Save Cancel Travel Cards screen Select a default printer for printing travel cards 62 Understanding the Travel Card Part I The information from your initial evaluation and previous treatment is printed onto a blank daily note form DN3c The form then becomes your Daily Note Travel Card and will be used for documenting symptoms findings and treatment for the current visit The information found on the travel card is outlined below Figure 19 Travel Card Upper left corner Pg 1 Ce Dx P 721 1 Cerv Neuro Vas Comp P 723 1 Cervalg Plan 2 12 2 P 723 4 Cerv Radi P 724 2 Lumbg P 724 4 Lum 3124108 3124108 Neuritis Radi P 729 1 Lum Myalg Myositi P 847 0 Cerv pnr Sae pex a Mm C5 C6 Dn Sbj BiNk Der gt S c gt Sp St f F s gt U Thrpy Ice 15 UML Cerv EMS 10 Xray Cerv NDS Mo C4 C5 Wdg Ant C4 C5 Lst Ant UML Cerv PNF SCM 10 C4 IStb w flx ext C5 SpnLam C4 Cv St PP Bi C1 Note rt hip repl P CP 30 Tx Resp VAS 8 5 SJECTIVE Beginning in the upper left corner Ce Dx Clinical Evaluation Diagnoses This section contains the diagnosis information from the patient s initial clinical evaluation Once a re evaluation is done the heading becomes Re Dx
155. s you can order using any of the following methods TO ORDER FORMS CALL 800 642 0600 FAX a forms order sheet included in the starter kit to 770 814 9988 Or visit us ONLINE http www docplus net For expedited service overnight shipping is available The Forms Overview In this guide the term FORM refers to various forms filled in by the patient and clinician The Forms are e Health Questionnaire 3 types HQ 0 HQ 2 and HQ 3 To be completed by a new patient on an initial visit or an existing patient upon starting a new case e Clinical Evaluation 2 types CE 0 2 or CE 3 To be completed by the clinician This form details the findings of initial exam e Radiographic Examination 2 types RD 0 and RD 2 To be completed by the clinician e Re evaluation 2 types RE 2 or RE 3 To be completed by clinician This form details the findings of the re exam e Automobile Crash AAQa The patient completes this form Details of the automobile accident such as road conditions number of vehicles involved etc e Accident Injury AI 0 2 The patient completes this form This form explains in detail the injuries of the patient e Daily Notes 2 types DN 3 DN 4 To be completed by the clinician e Outcome Measures 4 types RO RM NP HS To be completed by the patients as the clinician deems necessary to assess treatment and progress e Spanish Forms 3 types HQ AA AI These forms are t
156. s interfaced with Document Plus call before using this feature Examples of when you might assign a case number to a patient are listed below a A patient has not been active for a long period of time and then decides to return for care b If a patient while under an existing treatment plan has an accident and becomes a personal injury case Pillows In this section you may predefine different types of therapeutic or support pillows This section appears as part of the Plan section in your daily note report and will be preceded by The following was prescribed or followed by was prescribed Orthotics When bubbled Orthotics will be preceded by The following was prescribed or followed by was prescribed in the Plan section of your daily note report Tce Pack When bubbled Ice Pack will be preceded by The following was prescribed or followed by was prescribed in the Plan section of your daily note report 1 6 Bubbles These bubbles are user defined You may add up to 99 different items into each bubble These will appear in the Plan section of your daily note report and will be preceded by The following was prescribed or followed by was prescribed This is an ideal place to list nutritional supplements 47 25 Bubble the 1 on your form and write multivitamin on the line provided shown below in Figure 9 Figure 9
157. s of a moderate degree The patient is experiencing in the right wrist a frequent throbbing pain with swelling of a moderate level He says that in both sides of his neck and right shoulder there is no change in the pain with stiffness and soreness In his right wrist the pain with swelling is unchanged On a visual analog scale of 0 to 10 with 0 being no pain and 10 being the worst pain possible the patient reports his overall pain is an 8 He relates that his symptoms are worse in the morning The patient notes that he has not had any new provocative incident Figure 3 94 P y PAIN DIAGRAMS Please Mark The Location ot ho Pain 7 cere So NET Yn lo 0 5 s To s gum e V i Y Asl 2 A FAN yY ee NZ vy p fi i 9 9 ph A A B Yi Na bu a DATE 3 O DC Objective section Biomechanical Exam DN3c Form Pg 1 Figure 4 Objective section Daily Note report Sample Text OBJECTIVE The following conclusions are indicated by a palpatory evaluation of the cervical spine and right upper extremity Apparent pain to palpation is noted overlying the left upper cervical spine Tender musculatures are located at the right upper cervical area which radiates Pain to palpation is detected in the left middle cervical range Pain to palpation is present specific to the right middle cervical area which radiates Pain to palpation is apparent specific to the left lower cervical region Tender
158. s since the initial examination New Additional When a new injury or exacerbation of an old injury occurs you will want to bubble New Additional to document the additional diagnoses in the daily note When bubbled once the form is scanned a query screen will appear so that you may choose the new diagnosis codes from a predefined list This will remove the old diagnoses from the travel card and document the new Previous Unchanged New Additional When both of these are bubbled simultaneously the New Additional diagnosis codes will be added in front of the existing diagnoses and will be reflected in your daily notes 11 Bubble Prevs Unchanged as shown below in Figure 4 Figure 4 Assessment Section Diagnosis Page 2 Left DN3c Form Diagnosis Prevs Unchanged New Additional Assessment Progress Progress is documented here and references the initial visit 12 Locate Assessment Progress on your form see Figure 5 below Progress Use this section as needed Response to Treatment in Allows you to enter the patient s progress in terms of percentage of reduced spasm tenderness inflammation and also in terms of increased mobility and activities of daily living The other feature may be used to document an increase e g increase in work ability or a decrease e g decrease in hypertonicity 0 percent indicates no improvement and 100
159. sAL MASTERCARD AMEX o1scoveRO orHER CJ INSURANCE INFORMATION RELATIONSHIP TO INSURED SELF i iocus O oTtHeRO cHiLD C SPOUSE INSURED S EMPLOYER SAME AS ABOVE INSURED S SSN SAME AS ABOVE i onn pues INSURED S DOB SAME AS ABOVE O od Ld PRIMARY INSURANCE CO Ql hes Ir r3 ADDRESS D CITY stat ZIP coo 200g PHONEX POLICY NUMBER GROUP NUMBER SECONDARY INSURANCE CO ADDRESS CITY ZIP CODE PHONE POLICY NUMBER GROUP NUMBER AUTHORIZATIONS A f hereby autho niga seda any medical information necessary to process this claim and request payment of insurance benefits either to myself or to the who accepts assignme yyment o ppd any me dica bone efit from third parties for benefits s vraa pr izhar 0 be paid directly to this office authorize the direct pn settiement of my case and by any insurance the charges si sbeilhed ter podu cts and se S render an arrangement between an insurance carrier and myself F urthermore understand that a ports aae Oana nen women CONSON Mom I Ie insurance company and that any amount authorized to be paid dire sep hu o this office will be credited to my account upon receipt However clearly understand and agree that all services rendered to me are charged and that am personally responsible for payment also understand that if suspend or terminate my care and treatment any fees for IM E parece ndered be immediately due an ind payable Patient s Signature Bob ls A 9 Date 2 12
160. second visit The first item we will predefine is the Other 3 bubble under Today s Treatment Modalities ie 2 10 11 12 13 14 15 From the main menu select Utilities then Modify Predefines Select Daily Notes and double click DN3c An image of the DN3c form will appear Use the left right arrows at the top of the screen to view the opposite side of the screen image Locate Today s Treatment Modalities Page 2 lower left corner Locate the Other 3 bubble within this section Click the green bubble at the very top of the Other 3 column A smaller Modify Predefs screen will appear Each modality is entered into two category divisions They are Description and Expected Results The Location box at the top of this screen should read DNZ3 TODAY S TX Modalities Other 3 H1B16 30 Description Click Add Type electrical muscle stimulation into the Text ID box In the Travel Card Id box type EMS Check the Always Use box and click Save The Location box at the top of your Modify Predefs screen should now read DNZ3 TODAY S TX Modalities Other 3 H1B16 15 Expected Results In the Text ID box type EMS In the Predefined Text box type to reduce pain and inflammation Check Always Use and click Save The next bubble we will predefine is for the Cervical column in the Rehab
161. sit can be generated by selecting Outcome Measures in the Generate Documents screen or by generating re eval or final narratives 3 Review the outcome assessment with the patient After generating the report schedule a time when you will review the findings with the patient This 1s typically done on the visit following an initial examination or re evaluation e Establish a time when Health and Behavior Assessment consultations will be held in your office These are typically done on the visit following an initial examination or re evaluation e Only use Health and Behavior Assessment codes when a patient presents a problem e You are billing for a service and not the assessment tool You can find additional information regarding Health and Behavior Assessment codes in the ChiroCode Hot Topics Newsletter http www docplus net training chirocode pdf Outcome Assessment questionnaires should be administered on the patient s initial visit and at each re evaluation Each questionnaire and associated patient complaints are outlined below Neck Pain Disability Index Questionnaire This assessment is designed to measure the activities of daily living in persons with neck pain Use when patient complains of headaches neck pain upper shoulder pain upper back pain Roland Morris Acute Low Back Pain Disability Questionnaire This form is designed to be a simple and accurate measure of assessin
162. stallation of Document Plus You cannot change these fields 5 Report Empty Form If selected a warning message will appear whenever a blank form has been scanned The default setting is active 6 Warning Beep This sets the number of beeps that are heard when errors are displayed Default is Continuous 7 Patients Ordered By This feature allows you to choose how patients are ordered in the Pick Patient screen If Name is selected patients will be sorted alphabetically by name If DP Number is selected patients will be sorted by the Document Plus number assigned by your office PM Number will appear if you have an interfaced practice management software If selected patients will be sorted according to the number assigned by your interfaced practice management software 8 Screen This feature determines the size of your screen If Normal is selected the default settings apply If Maximized is selected your screen will always appear maximized If you choose Custom you are able to adjust the height and width settings manually 9 System Id This section contains Document Plus technical support information Figure 5 Set Up Miscellaneous 2 screen F Document Plus Version 10 00 Miscellaneous MISC EXE WkSta ServerActv Sz X Setup Information Settings Daily Notes 1 Daily Notes 2 Consult Notes Miscellaneous 1 Miscellaneous 2 Cover Letters v Policy v Claim it
163. stance 4 5 Movement against gravity and resistance but less than normal 5 5 Normal strength e Compression Tests D1c O Cervical Compression Test D1c1 You may choose to mark the Negative In All Positions Except bubble and the report will reflect that all positions were tested and found to be normal If you find that all compression tests are normal with the exception of one or two you can mark the Negative In All Positions Except bubble and choose the deficiencies found There may only be one choice for Negative and Positive You may mark either Dull Pain or Sharp but not both Left and Right may both be marked There is also a bubble for the descriptor Paresthesia that may be added There are additional bubbles in this section of Cervical Shoulder Arm Hand Fingers One or all of these bubbles may be marked and are used to indicate where pain was produced in association with the test or where the pain radiated to For example If you mark Cerv Shlidr Arm the report will state that the test produced pain in the cervical spine that radiated to the patients shoulder and arm Adson s Test D1c2 Only one choice of Negative or Positive may be marked Both Left and Right may be marked The down arrow indicates a decrease in Pulse Valsalva D1c3 Only one choice of Negative or Pos
164. subsequent visits bubble symptoms not changed the text will use the word unchanged instead of worsening repetitiously 9 Adjustment Reason If Subluxation is selected to correct a subluxation will be added to the Treatment section of your daily note report 10 DN 3 Complaints If HQ2 is selected the listing of subjective complaints will be ordered from HQ2 and listed as primary and secondary If unselected it will list everything as primary on daily notes It is our recommendation that you leave this unselected 11 Report Visits This Plan If you select this the information you bubble in the Visits This Plan area of the daily note form will appear in your daily note report If unselected the information will only appear on the travel card 12 Adjustments If Segments is selected adjustments documented on the daily note form DN3 Pg 1 Today s TX section will appear in the treatment section of your daily note report as specific segments Example A manual osseous adjustment is applied to C5 and C6 If Ranges is selected the information will appear in general terms Example A manual osseous adjustment is administered to the lower cervical spine 13 Travel Card Complaints For the travel card complaints section you may choose whether the symptom information is pulled from the current daily note DN form or the initial Health Questionnaire HQ Default is cu
165. te a query for you to enter the information Recommendations This section is available if you want the report to indicate what further measures of referrals you intend for the patient Only once choice of R Referral or I Immediate may be marked for any one item For example if you marked an T for Urinalysis and an R for MRI Examination the report would indicate The patient will immediately undergo a Urinalysis Additionally the patient will be referred for an MRI Examination to further assess the nature of his her condition There are also additional bubbles that are query driven if you want to indicate that Medications or Supplements were prescribed for the patient Case Description Discussion Any Additional Info This section is used if you want the report to indicate any additional information regarding the patient such as an Impairment rating or Permanent Disability Any bubble may be indicated in the section but it is query driven and the information must be either input or predefined Prognosis This section 1s used if you want the report to indicate the patient s prognosis Only one choice may be marked and Other supersedes other responses All general measure associated with condition have been reviewed If you mark this bubble this exact sentence will be added to the report Potential risks have been described and the patient has acknowled
166. ted SrRs Pain P ROM FIxzMoRs Ext SrRs P RtLatFlx P Thoracic Region Spinal Examination Thor Spinal Examination SpnEx SpnEx Tl finding T12 finding finding Right Rt Left Lt Bilateral Bi Spasm Sp Right Rt Left Lt Bilateral Bi Midline MI Tenderness Tn Articular Fixation AF Malposition Mp SpnEx T1 BiSp T2 RtSp BiMITn T3 RtSp AF Mp T4 RtMITn Lumbosacral Region Orthopedic and Spinal Examination LS Spinal Examination SpnEx SpnEx L1 L finding L5 L finding Sac L finding 1 SI SI Finding2 Coc Coc Finding3 L finding Right Rt Left Lt Bilateral Bi Spasm Sp Right Rt Left Lt Bilateral Bi Midline MI Tenderness Tn Articular Fixation AF Malposition Mp SI finding Right Rt Left Lt Bilateral Bi Spasm Sp Right Rt Left Lt Bilateral Bi Tenderness Tn Right Rt Left Lt Bilateral Bi Articular Fixation AF Right Rt Left Lt Bilateral Bi Malposition Mp Coc finding Tenderness Tn Articular Fixation AF Malposition Mp SpnEx LI BiSp L2 RtSp Bi MITn AF Mp SaczRtMITn SI BiSp BiTn Coc Tn Mp Straight Leg Raise SLR SLR Right Rt finding Left Lt finding finding Back Pain BKP Leg Pain LgP 30145160190 SLR Rt BkP SLR Rt LgP 45 Lt BkP LgP 60 Braggard s Brg Right Rt Left Lt Bilateral Bi Brg RtBrg 130 Well Leg Raise WLR Right Rt Left Lt
167. the Today s Treatment Modalities section you will notice that these items must be entered in two parts Description and Expected Results Description After clicking Add enter the name of the modality into the Text ID box in lowercase letters Here you can choose a Travel Card ID The Travel Card ID will appear on the travel card and should be a recognizable abbreviation of the modality You may also enter the bill code for the item in this screen Click Close when you are finished and the Expected Results screen will appear Follow the directions 1n the section titled Expected Results to complete your entry Examples of what you might enter under Description Name of Modality Text ID Travel Card ID electrical muscle stimulation EMS neuromuscular re education NMR cold laser CL Expected Results In this screen you will want to enter the results expected from administering a particular modality Enter an abbreviation representing the name of the modality in the Text ID box Drop down to Predefined Text and enter the expected results for the modality Examples of what you might enter under Expected Results Modality Text ID Predefined Text electrical muscle stimulation EMS to reduce muscle spasm and inflammation neuromuscular re education NMR to improve circulation and decrease muscular tension cold laser CL to
168. the SUBJECTIVE portion of your DAILY NOTE report Symptoms Section I This section details the current symptoms the patient is experiencing and can be completed by the patient staff or doctor Fill in as much or as little as is applicable to the case 3 Turn the form to Page 2 Locate Symptoms Section I see Figure 2 below 4 Locate RIGHT SIDE on your form Drop down to the Neck area and bubble the symptoms as shown in Figure 2 below When complete you should have bubbled from left to right Pain Stiffness Soreness Severe Sharp Shooting Frequent and Unchanged 5 Do the same for the LEFT SIDE of the Neck Figure 2 Symptoms Section I Page 2 Upper Left DN3c Form SYMPTOMS If Your Symptoms HAVE NOT Changed Since Your Last Visit Indicat if Your Symptoms HAVE bakgear Last Visit Please Com a gt ife Tem wl ffHiead Neck e Coe ss Upr Back Mid Back Low Back Shoulder cro cx MOM Elbow Wrist i SO SOS aM NS P eu Gr aM SF a os gt Q UN uua SVS RIGHT SIDE Mid Back Low Hack P amp i A i gt c Shoulder Ho CY E gt cS icv a oe Elbow i gt cD a 5 ES CN Mrs oe Wrist mici CD ao c claw uc Mono Jo a_i Hip j u I z 5 Yi TE Knee i gt oD c amp DA cM Ankle h I 5 x m Foot Io c8 CN CE LEFT SIDE
169. the question on your form section B1 HQ3 form 2 Enter the query In the Explanation box an explanation and example will be provided advising you how to properly enter the query 1 e with a full sentence or by typing one word entries Type your entry into the Text Hand Written on Form field at the bottom of the screen See Figure 25 below Figure 25 Information Written On Form screen FA DocumentPlus 9 010A Document Generation DOCUMENT EXE WkSta ServerActv WAIT Generating Patient History Summary HQ 3 Information Written On Form Page Number i Patient Jones Bob Mr ldit3 Document Records Sys Serial 422194 Date 01 12 20 Pg H3 Pg 1 HQ3 Pot Jersion A Location on Form Qomos D 70 Bubble Text Date Spinal Neck Back Ribs effets Began Pati sn s Complaints When Did Your Neck Back Complaints Begin Date Enter the date complaints vegan Symptoms Began Example Symptoms Began 64 30 2001 Explanation and Example 9 Append Clear ext Hand Written On Form Missing C Insert y 12 12 2011 Text Hand Written on Form EG NTSN ENDS BU Beste ROUND NOYEDTUM 3 Once you have finished Click OK and the next query to be entered will appear Once you have entered a query it will not come up again automatically the next time you generate a document 32 Click Skip and the query will be
170. thirty minutes 22 each evening with feet elevated increased water intake by 16 oz per day PRN This bubble can be predefined to accommodate changes in visit schedule Examples are outlined below Example of text as it appears in the daily note report The patient s visit schedule is altered to 33 Examples of what you might enter to complete the above statement 3x per week for 2 wks 2x a2 66 per week for 4 wks then I x per week for 4 wks patient to return as needed The entire Rehab Therapy section is user defined When an item in this section 1s bubbled and the form is scanned a query screen will appear You can predefine specific rehabilitative therapies stretches and or exercise protocols into any or all of these columns You may enter up to 99 items in each column In this section the items listed across the top can redefined in the program However since the printed text cannot be changed it is our recommendation that you categorize items according to the headings that appear on the form For example Create a pick list of all cervical exercises and therapies in the Cervical column When predefining this area the name of the therapy stretch or exercise protocol should be entered into the Text ID box and a partial sentence including the therapy and targeted area or region of the body should be entered into the Predefined Text box Examples are outlined below Example of text
171. ting pain during the test e Other 1 DIf Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text e Other 2 D1g Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text e Other 3 Dih Negative and Positive bubbles are provided for you to add in your own tests Please see explanation of Queries and Predefined text e Of Additional Note D1i You can enter information for these twelve bubbles each time you want to add additional information or you can predefine lists of customized entries to choose from D2 iid Thoracic Spine e Range of Motion D2a o If you mark the Normal In All Positions Except bubble you do not have to mark anything else in the section and the report will reflect that all ranges of motion in the thoracic spine are Normal and the Normal degrees will be listed If you find that all ranges of motion are normal with the exception of one or two you can mark the Normal In All Positions Except bubble and choose the deficiencies found You may also just mark a particular range of motion tested and skip the rest o The numbered bubbles in each of the ranges tested represent degrees and Tens may be combined with Units o Though it is not required
172. tive for details Under extended warranty should a problem occur with the scanner simply call technical support at 800 642 0600 They will assist you in determining the source of the problem and if a part of the machine is defective will ship you a loaner scanner within 24 hours Your obligation under this plan is to return the defective scanner using the same carton in which the new scanner arrived If a scanner is not covered under warranty charges will apply for parts labor and shipping Getting Started Computer Requirements a Computer Requirements Processor Pentium III 800 Pentium 4 800 or faster s arg 300 MB LGB or more RAM 256MB 512MB or more Ports Document Plus Supplied USB 2 0 port USB 2 0 port Drives CD ROM CD ROM Printer Padre LA Pend eel Mouse Any Any SOFTWARE Operating Systems Supported Windows 2000 Windows XP Windows Vista Word Processor Microsoft Word 10 0 or higher Internet Access This allows us to connect to your computer remotely Required for virtual training Customer supplied and required For Technical Assistance call 1 800 642 0600 Preparing Your Computer Complete the following steps to prepare your computer for installing Document Plus If you need assistance please call technical support at 800 642 0600 Confirm that there is at least 500 MB of free space on your hard drive Temporarily close or disable any programs Install Microsoft Word
173. uld bubble 3 in the column farthest to the right in the Patient Number section See Figure 1 Pg 39 e When using forms with multiple sheets separate them at the perforated fold before scanning e Forms are fed one sheet at a time e The forms must be fed into the scanner according to the following Odd numbered pages should face up 1 e 1 3 5 and 7 and the bottom should go in first e Once the forms are scanned press Enter The bubbled information is then saved into the program e Forms for different patients may be scanned at the same time Each form that is scanned is saved for the specific patient according to the Patient Number bubbled on the form and the unique serial number at the bottom of each sheet Figure 19 Form Orientation into the Scanner Double Click on the Image below to play Form Feed Direction 23 1 Click the Scan Forms button on the Main Menu see Figure 20 below Figure 20 Main Menu z FA Document Plus 10 00 t7 w ES Databases Scan Forms Help Word Document Plus Version 10 00 W kSta ServerActy NUM E 4 53 02 You are now in the Forms Scanned screen See Figure 21 below Figure 21 Forms Scanned r4 Document Plus Scan_VX SCAN FORMS Scan Form Sht Serial ate Save Exit i r Generate Daily Notes after is Scanning E ach DN Form To Navigate the list Use PageUlp key PageDown key Arrow keys or the Mouse J
174. ure of your X Ray image while it 1s up on your view box 2 Plug the camera in to your computer If a camera wizard program appears you will want to cancel it If you get a screen that says what do you want to do click take no action 3 Find the drive letter of the camera that the pictures are on See instructions below e Click My Computer Look for a drive that says removable drive disk Once you locate the drive make note of the drive letter close My Computer and open Document Plus 4 Scan your forms including the Radiographic RD2 form and check to make sure to mark the Include Images bubble at the top left of the RD2 form Once the forms are scanned press Enter or click Documents to go to the Generate Documents screen for that patient 5 Select the desired report and click Generate Once the query screens for the Radiographic form appear you will be prompted to locate your X Ray images See Figure 1 below Figure 1 Locate RD Image Files screen FA Doc umentPlus 9 010A Document Generation DOCUMENT EXE WkSta ServerActy Locate RD Image Files Repeat Steps Enunar Jones Bob 3 Exam Date 01 1 2 2012 6 8 below for View Image Region Status e each view Cervical Hissing Cervical Lateral Missing listed here Thoracic AP Missing Lumbosacral AP Missing en Eee Rotate Left Rotate Right I Clinical Evaluation Initial Final
175. vailable in the setup screens for daily notes are outlined on Pages 72 78 of this manual NOTE The default query option is set to Scan enter queries after scanning To change the default to Document enter queries when generating documents complete the following steps 1 From the Main Menu select Setup 2 Click the Daily Notes 1 tab at the top of the screen 3 Locate the DN 3 Query heading and choose Document 1 Scan the DN3c form according to the guidelines on Page 23 2 If you have set your default query option to Scan enter the queries according to the guidelines on page 32 33 If you have set your default query option to Document skip this step and continue with 3 below 3 Press Enter on your keyboard or click Documents when scanning has completed 55 The process of generating the Daily Note report is similar to generating reports in Tutorial 1 1 Notice that you are in the Generate Documents screen for Bob Jones Select Daily Notes under Reports and click Generate You are now in the Daily Notes Select Visits screen See Figurel15 below The lower portion of this screen contains a number of different options These options are outlined below Medicare When selected the patient s date of birth and Medicare number HIC will appear at the top of the report the doctor s signature will appear at the botto
176. visit number 2 the number of total visits in the current treatment plan 12 and the total number of accumulated visits for the patient up to this point 2 See Figure 19 Pg 63 Schd This section reflects the patient s visit schedule 3 wk for the current treatment plan n Re This section reflects the Re Evaluation date entered into the Information 2 screen of the patient s database in the previous step of this tutorial If no date was entered in the previous step of this tutorial I CE would appear in this section and the date reflected would be the initial examination date XR This section reflects the X Ray date entered into the Information 2 screen of the patient s database in the previous step of this tutorial Adjt The information in this section reflects the adjustments bubbled under Today s Treatment General Listings on the previous visit Thrpy This section reflects the therapies documented in Today s Treatment Modalities and in Rehab Therapy on the previous visit Tx Resp This section reflects information documented in the Progress and Response to Tx in areas on the previous visit Additional information about the previous visit s appears in its respective section on page 1 of the DN3c form Objective section See Figure 20 Pg 65 e To the right of Leg Length Deficiency you should see R1 8 e In Biomechanical E
177. w the instructions under Step 4 Printing Travel Cards on pages 61 62 Once the second travel card has printed continue the tutorial on Page 68 67 Understanding the Travel Card Part II Understanding the travel card is covered in detail on Pages 63 65 of this manual However there are items we marked on the second visit and did not mark on the first How these items appear on the travel card are outlined below Adit Mm C5 C6 EU q V In the Tx Resp section of the travel card shown above in Figure 22 you will now see abbreviations for the items marked in the Progress and Response to Tx in areas of the DN3c form on the previous visit Prog I Progress Improving VAS 7 Visual Analog Score from the pain scale 7 S 10 Reduced Spasm 10 T 10 Reduced Tenderness 10 I 10 Reduced Inflammation 10 M 20 Increased Mobility 20 A 20 Increased Activities of Daily Living 20 You will also notice that on the far right side of the form in the Thrust Report section you now have columns 1 One visit ago and 2 Two visits ago Remember that the travel card will print listings from up to five visits The items listed under 1 ALWAYS reference the most recent visit The dates of those visits appear on page 1 of the DN3c form in the upper right corner above Patient Name See Figu
178. xam under left and right you should see the abbreviations for the items bubbled on the previous DN3c form Left XS Right XSTIR e In Posture you should see an R to the left of Head Tilt e In Forward Flexion you should see a C to the right of Cervical e In Range of Motion you should see D to the right of Cervical Today s TX General Listings See Figure 20 Pg 65 e To the right of Wrist in the upper extremity column you should see an R and you should see INST above that Thrust Report e To the right of the three column Thrust Report you should see a 1 beside each section marked for the last visit followed by the specific listings for that area See Figure 21 Pg 65 64 Same Assessment Leg Length Deficiency Equal a eR VUES Left je Right TODAY S TX General Listings Biomechanical Exam K eo WWW SO SME MD SS ES LEFL_ sad ICTUTT Li R an ik Foot gt Clavicle gt Patella S Elbow co Coccyx Posture Forward Flexion wif lt Psocis Head Tilt Cervicalc lt Q High Shoulder Lumbar gt Hore lt lt High Hip cec Thumb Antalgia Patient Tolerated Procedure Well i Hc oar eee Range Of Motion Cervical DorsoLumboar NOTE The 1 represents One visit ago NOT Visit number one Each time a travel card 1s print
179. y Name C Id Number Daily Notes Edit Batch Session When generating batch daily notes you can use this feature to edit a single daily note within the batch This feature will generate a separate note for each patient and allow you to edit a specific note by selecting it from a list Figure 3 Batch Daily Notes Criteria screen FA DocumentPlus 9 010B Batch Daily Notes DN_RPT_A EXE WkSta ServerActv Batch Daily Notes Criteria Dates From 0670472004 To 0270372012 Order Ascending C Descending Auto PI Only Doctor Clear All Doctors Report By Name C ID Number Format C Paragraph SOAP Batch Report Type All Patients In One Document c Separate Document For Each Patient r r Report Signed B Sign Note None Attended Signed By Signed By Doctor Your it 1 For Doctors Your cH 19 Generate Notes Available Lists Main Menu Daily Notes Generate Batch This feature enables you to generate batch daily notes o Generate by a range of dates patient name or patient number o You have the option of including all patients in a single document or generating a separate document for each patient 115 e Forms Scanned This feature enables you to print a list of scanned forms for a specific date or range of dates o Generate by scan date or exam date o Sort by DP Number or Patient Name e
180. your Document Plus system to an interfaced billing program NOTE If your practice management billing software utilizes short codes or office codes you will need to make sure you enter those codes instead of the standard CPT codes Print Patient Labels This function enables you to print mailing labels for patients by name ID number last activity or birth date View PulStar Data If you are a PulStar user this function enables you to view the data that is being imported into Document Plus from PulStar The numbers represent stiffness in the patient s vertebrae If the PulStar interface is enabled the imported information will be printed on the DN3 form next to each corresponding vertebral level Print Medical Records This function enables you to access edit and print scanned images and records for a selected patient NOTE When using this function you can access scanned records and images even if you have no forms scanned for the selected patient Export CBP Data This feature will be used in the future for research and development purposes Main Menu Use this button to return to the main menu 118 APPENDIX H Include Images from the Radiographic Form RD2 The Radiographic RD2 form allows you the option of adding your radiographic images to your documentation Follow the instructions below to utilize this feature 1 With a digital camera flash turned off take a pict

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