Therapist Documentation: Filling Out a Form

 Fusion Enterprise understands that managing all of your cases is a critical function of any practice. We have created Fusion Enterprise to be easy to use and 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 Therapist Documentation with Fusion Enterprise.

Filling Out a Form

After adding a new form, the form will display and allow you to start filling it in. This form should look and feel much like a paper evaluation form with some exceptions. Let’s take an example evaluation form and work through it from top to bottom. The following is the Elbow Evaluation, which is just over 2 pages long:

Let’s now look at each section in a little bit more detail. Again, the purpose here is not to show you everything there is to know about an elbow evaluation but rather to explain to you the concepts used in filling out an evaluation.

The very top section of the evaluation is the header.

This header is loaded with data from the database at the time the form is created. In the evaluations that come with Fusion Enterprise, this header information is dynamic, meaning that if you change any of the information in the database, the next time the form is loaded, it will change to reflect this new information. The logo may be changed without going to the form designer by setting the Therapist Forms Logo in the Administration | General Information dialog.

The next section is the subjective section.

In the interest of consistency, all of the stock evaluations come with one of two subjective blocks, those with diagrams and those without.

The entries on the left bring us to our first entry control. This control is a text box and allows you to type in your response.

Pressing tab allows you to jump to the next control, and shift-tab navigates to the previous control.

The second type of control that we encounter here is the drop-down box found for recording the Pain Level.

While there are options to choose in the drop-down, you can just as easily type in your response.

The diagram is one of the few controls we have that has a separate editor. Right-click on the diagram and select Edit…. This will display the image annotation dialog.

The diagram shows on the right side and the drawing controls are on the left-hand side. There are 10 different operations to choose from in the drawing controls; they are as follows:

Drawing Controls

Select Arrow	Select different drawing elements and edit them.
Hollow Box	Draw a hollow box.
Fill Box	Draw a shaded box.
Hollow Circle	Draw a hollow circle.
Filled Circle	Draw a filled circle.
Line	Draw a line.
Arrow	Draw a line with an arrow on the end.
Text Tool	Type text onto the drawing.
Delete	Delete the selected drawing element.
Stamp	Place an X on the drawing to mark it.

For example, let’s draw an arrow on the elbow. The first thing you would do is select the arrow tool by clicking on the 7th button. Then, position your cursor where you want the arrow to start, and, while holding down the left mouse button, drag the mouse to where you want the arrow to point.

You should have a diagram that looks as follows:

You will notice several different things. The first is there are now properties available in the grid to the left. These allow you to set the LineColor, LineWeight, and Opacity of the line element. Changing any of these will modify the line you just created. The second thing you will notice is the boxes on each end of the arrow. This indicates that this control is selected, and you can click on and drag any of the boxes to change the length or angle of the arrow line.

The other controls work very similarly. To draw a filled circle, we would select the filled circle and click-drag to make the circle the size we wanted. By modifying the properties, we can set the fill color and border colors, and we end up with a diagram that looks as follows:

If we wanted to edit any of the elements we could select the Select Arrow (first button), and then click on either the arrow or the circle. We could then modify the properties.

When we are done, we select Done, and the drawing will now show up in our evaluation.

The objective section contains yet another type of control. This control is the measurement control.

This control contains two columns of drop-downs labeled Right and Left. There is also a comment box at the bottom. We can either use the information in the drop-downs or type in our actual measurement. You will also notice that there are two other column headings here, Prev R and Prev L. If we had done a Flow Forward to open this form then the measurements from the previous form would show up in these columns, and we could do a comparison if desired.

Some measurement controls also allow you to change the name of the measurement on the fly, such as the one shown below:

The measurement under Usual Activities allows you to specify your own measurement at the time of the evaluation. When designing your own forms, you can specify which measurements are modifiable and which are not. The designer also has the ability to allow you to modify the control header as shown below.

Up to this point, we have encountered four different types of controls: text box, drop-down, annotatable image, and measurement (which is made up of text boxes and drop-downs). There are three other controls that we use in the evaluation forms and one more that we use elsewhere. The Problem and Goal control.

This control allows you to enter in problem and goal sets for the patient as well as specify the length of the goal and the status of the goal (in progress or met).

The Intervention Control works much like a drop-down control except that the available values in the drop-down are pulled from the charge code list that is currently being used.

This allows you to select the intervention you plan on using for a given patient. The last control to be found in our evaluations is the digital signature control.

If you are logged in as the therapist who treated the patient then you will be given the opportunity to sign the form. Once a form is signed and saved, it may not be modified. Right-clicking the signature control allows you to select Sign Form. If you have scanned in a signature and saved it on the therapist’s table then the signature will show along with the date and time of the signing. Otherwise, a ‘Signature On File’ is used in its place.

We have found that both are equally valid.

The last control we are going to cover is found on the daily note, and that control is the check-box.

This control is very self-explanatory.

While our stock forms only use a small handful of controls, there is a lot of power to be had when the form is filled out. All the fields in the form are stored in the database in a name format, so that they may later be queried and reported on.