Adding Documentation

Permissions! Clinic Staff must have Administrator, Billing Assistant, Billing Manager, Clinical Director, Front Office, Operations Manager, PTA, Staff Therapist, or Therapy Student assigned in order to manage some of the features in Charges & Documentation.

Fusion Enterprise understands that managing all of your cases is a critical function of any practice. We have created Fusion Enterprise to not only be easy to use, but also allow any therapist to be able to sit down and with very little instruction be able to complete an evaluation or a daily note. We have designed the actual documentation to be as customizable as possible. This series of introductory articles will cover the essential aspects of the Charges & Documentation with Fusion Enterprise.

The first step in adding a note for a patient is to be sure to select the proper visit in the Visit List on the left-hand panel.

Choosing Add Form | New Form displays a window showing all the forms you currently have in Fusion Enterprise. Select a form to complete a note for this visit. Fusion Enterprise provides templates for evaluations for major body parts, as well as Additional Notes, Daily Notes, and a Flow Sheet. Additionally, you may edit these templates or create your own from scratch.

Our forms are designed to be used for Initial Evaluations, Re-evaluations, and Discharge Evaluations, as indicated by a Title dropdown. Using Flow Forward allows the direct comparison between previous and current measurements, as well as minimizing data entry. To use flow forward, choose the completed note you would like to flow forward from (i.e., copy) and choose Add Form | New Form Flow Forward or Add Form | New Form Flow Forward to Same. The latter function allows you to bypass the Select Form screen and will automatically open a note of the exact same type (i.e., Knee Evaluation with Diagram).

Once a form is open, you can fill it out as needed. Although much of the form consists of “free- type” areas (text boxes), there are also dropdown menus with prefilled choices. You are not restricted to the items displayed in the dropdown, but you can use these options to save time. The Problems and Goals areas are unique. Double-clicking in the Problem area presents a list of problems to choose. Once you’ve chosen a Problem, double-clicking in the Goal area presents a list of goals specific to that problem. Some of these problems are open-ended sentences. It is important, however, to choose the problem and the goal prior to completing the sentence. As with the other areas, you are still free to type whatever you would like in these areas.

Once you are finished with your form, you are able to sign it. This will lock the form, and the previously-dynamic fields at the top (Referring Physician, Diagnoses, etc) will no longer be updated. To sign the note, right-click on the Signature panel and choose Sign as Primary or Sign as Secondary. If the note needs to be signed by two therapists, the Secondary should sign first, and the Primary will sign last. This is typically used when a PTA is treating the patient and the overseeing therapist needs to cosign.

You are now ready to print your note, if desired. You can print the entire note exactly as it appears on the screen, or you can utilize a Rollup to print a modified version. Right-clicking within a note displays the following menu:

Note Menu

Rollup \| Select Template	Allows you to choose an existing rollup template to use for this note.
Rollup \| Define Template	Allows you to link a new rollup template to this note.
Print	Prints the note.
Spell Check	Shows misspelled words in fields that have spell check enabled.
Save	Saves the note.
Save and Close	Saves and closes the note.
Close	Closes the note.

A rollup is a Word document that has been created to merge information from the evaluation. Some rollups provide basic, summary information from the note. The Full Rollup, however, will display anything that has been filled in on the note. Anything left blank will disappear.

NOTE: Individual rollups are not intended to be edited. They should only merge information from the evaluation. Any changes made to the displayed rollup are happening locally to the machine and will not be saved in the patient’s Attachments.

Once a note has been signed, it is no longer editable. You can, however, use Open Unsigned Clone to create a copy of the note that does not have a signature. That version of the note can then be changed, saved, and signed.