When setting up a Treatment Plan, it is necessary to identify the Region of the patient’s body that was or will be treated. This point of documentation is required by all State Boards, the Federal government, and many insurance programs.
This Regions section includes the name of each body area that any Modality could be applied to.
Click on Regions to open the Customize Plan Verbiage: Regions window (figure 5).
Figure 5
Before creating a new Region, place a check in the box to Show Inactive. The desired item may already exist in the system but be classified as Inactive. If it is Inactive, by clicking Show Inactive all the Inactive items are returned to the list. Click on the item to highlight it, uncheck the Inactive checkbox just below the Region Name and click the Save icon on the left in the Region Listings box.
There are 2 methods of creating a new Region. Both are done using the icons on the upper left of the window.
1. New Icon: Create the name of the new Region by clicking on the New button on the left under the heading of Region Listings. In the Region box on the right, type in the name of the Region, and enter a Mnemonic. The Mnemonic is essential to the computer’s internal functions and MUST be entered. This is the only place where you will see the Mnemonic. When finished, click on the Save button on the left that is adjacent to the Clone button.
2. Clone Icon: If the new item is very similar to one that already exists, to minimize the verbiage entries, click on the Clone button. Enter a new Name and a new Mnemonic for the cloned item. A new item created by using the Clone button will contain all the verbiage from the original Region item. For each verbiage iteration in the Cloned item, it is necessary to review every iteration and revise the verbiage to be appropriate for the newly created Region. When finished, click on the Save button on the left that is adjacent to the Clone button.
The Region list can be rearranged by using your mouse. Click on a Region Name. While holding the left mouse button down, drag the Region item either up or down the list. When you let go of the mouse button, the Region item will now appear at that point of the list. The order which you see on this screen is the same order in which the Region list will display in the Assessment window.
Regardless of which method was used to create the new Region, it is required that the Verbiage is either created or verified. This is done in the Verbiage box on the lower right.
In the Region Listing column on the left, click on the Name of the Region so it is highlighted. The first Verbiage iteration for that item will appear in the Verbiage box on the lower right. If there is NO Verbiage, the box will remain blank. If there is Verbiage, use the Right and Left Arrows to scroll through the Verbiage iterations for this specific Region.
Note that each iteration for a Region is NOT a complete sentence. It is only the name of that body area.
Each Iteration Template is assigned a Weight between 1 and 9. This Weight determines the frequency with which each iteration will be used by ChiroPadEMR. The higher the number, the greater will be the randomization of the verbiage. For example, if there were only 2 Iteration Templates and Template A has a Weight of 1 while Template B has a Weight of 9, for each time Template A appears, Template B will appear 9 times. For the greatest degree of text randomization in the SOAP notes, give every Iteration Template a Weight of 9. Note that the more iterations, the greater will be the variation and randomization in the SOAP Notes.
If the Verbiage box is blank, or if there is a need to add another iteration to those that already exist, click the New icon at the top right of the Verbiage box. The box will be blank. Type in the Region Name and click the Save icon that is above the Verbiage box. If the Region has more than one synonymous Name, then enter it as another Verbiage iteration. Should another Verbiage iteration be desired, repeat the process of creating a new iteration, and continue repeating this process until all the Verbiage iterations that are wanted have been entered for the selected Region.
Editing the Region Verbiage is easy to do. In the Region Listing column on the left, click on the Name of the Region that is to be edited so it is highlighted. Use the Right and Left Arrows to scroll through the Verbiage iterations to find the item to edit. Edit the Region Verbiage and click the Save icon.
If a mistake is made and it is necessary to Undo the Verbiage Template that was created, click the Undo icon, the circular arrow between the Save and Delete icons. Note that Undo functions ONLY BEFORE the Save icon has been used.
If it is decided that a specific Verbiage iteration should be permanently removed from the system, locate the item and click the Delete (Garbage Can) icon.
There may be one or more Region items that are not wanted. To take a Region off the list, click on the Region Name in the Region Listing box, place a check in the Inactive box in the center of the screen, and click the left Save button above the Conditions Status Listing column. This hides the item but does NOT remove it from ChiroPadEMR.