Forms

### Registering a New Patient

To register a new patient, click on the “Register New Patient” button in the top left of the AT Dashboard (shown below).

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This will direct you to the patient registration form. On the patient registration form, complete the fields with the patient’s personal demographic information.

***All fields with an \* are required to submit the form***

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### Patient Username and Password

The patient username is the personal patient id that your patient will use to access the system from home.

It should be something simple to remember and unique to each patient.

We recommend using a standard system for all patients, such as first initial, last name, or first name, last initial.

John Doe = jdoe or johnd

*Please note that you cannot register two patients with the same username. If a username is already in use, the form will submit but the patient will not be available within the patient list window.*

Primary Care Physician, Guardian 1, and Guardian 2 information is not required for patient registration, but is recommended for complete documentation.

Once all of the required fields are completed, click on the "Submit" button to register the patient. You will be returned to the AT Dashboard, and your newly registered patient will be available in the Patient List.

### Daily Login

The Daily Log-In is a tool for documenting all patients who receive care in the athletic training room. This system feature was created specifically for capturing services that may not normally require an injury evaluation or other documentation. It can also be used to track the number of new evaluations, treatments, and other daily practice activities rendered to a patient by an athletic trainer on a weekly, monthly, or even yearly basis.

When entering the athletic training room for care, the athlete will log into the system and select the reasons for their visit. The daily login portion of the EMR functions independently from the Athletic Trainer portion of the system, so both can be open simultaneously.

***A patient must already have their name and demographic information registered in the system to utilize the "daily login" feature***

To reach the Daily Login from the AT Dashboard, click the “Daily Login Page” button in the upper right-hand corner of the screen. This action will log you out of the Athletic Trainer role within the site and open the Daily Login Homepage.

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Once on the Daily Login Homepage, the patient will type in their first name, middle initial, and last name, OR patient “username”

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Once the patient logs in with his/her name or already registered ‘username’, he/she will be redirected to a new window. This page captures the following information regarding the patient’s care for the day:

1. A reason for the visit: (New Injury, Current Injury, Prevention)
2. Current Sport or Activity
3. Body Part
4. Side of Body
5. Services being provided: (ie. treatment, evaluation, taping, ice pack/hot pack, wound care, other.)

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Once complete, the patient can then “Submit” his/her information. For security purposes, once a patient completes and submits his/her daily login information, the system is redirected to a blank daily login page for the next patient to login.

In order to ensure that all information entered by patients is accurate, clinicians can log into the system and edit the daily login page as needed.

To monitor and adjust the accuracy of the daily login page:

1. Login to the EMR website (www.core-at.com) using the “Athletic Trainer” tab.

2. Once on the main page, you will click on the button labeled “View Daily Logins”.

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3. On the daily login page, you will see a list of all patients who logged into the EMR system. The default time range is for the current day.

This “patient window” provides a quick look at all patients who logged into the system during the selected time frame. From this list you can see patient names, sports, services selected, and the date of login. In addition, the right hand column indicates whether the login record has been locked from editing.

4. to view detailed information about the patient's login, click on the row containing the patient's entry.

5. You will now see the detailed information that the patient entered into the system. This includes the reason for visit, body part, side of the body, sport, and selected services. Here, you can modify body part injured, side of body, type of treatment, and the patient’s sport.

#### Navigation Tips

On the daily login page, if the patient enters “new injury” for the reason of the visit, they will be granted access to the injury demographic form. Access to the injury demographic form will enable them to complete the necessary documentation and return directly to the login screen. If the patient enters “current injury”, the system will attempt to match the injury based on the body part entered. If the system can match the injury, then it will provide a link to a daily treatment form, which allows the clinician to complete the necessary documentation at a later time.

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6. before "locking the patient's login information, you must first complete the patient's injury demographic form or daily treatment form, depending on what service was provided on a given day. If these forms are not completed before "locking" the patient's login information, the program will be unable to link the patient's login with the injury demographic or treatment forms.

7. Once these forms are complete, to confirm that the patient’s information is accurate, you will check the box labeled “Is locked” and click “Update” to secure the information.

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8. Once the patient’s login information is locked, you will notice that the right hand column now reads “true”. You will no longer be able to make future changes to the information.

Another feature of the daily login page is the ability for the clinician to track the number of patient visits, treatments, new injuries, evaluations, etc. This feature can be accessed by clicking the “View Totals” box at the bottom, center aspect of the screen.

Additionally, if you would like to track patient visits over a specific period of time, you can adjust the “start” and “end” dates at the top of the page. This tool can be used to track daily, weekly, monthly, or even yearly services rendered to a patient by an athletic trainer.

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### Injury Demographic Form

***An injury demographic form must be completed to access the other documentation forms within the system.***

The EMR system’s injury documentation format is broken down into two steps - the injury demographic and the injury evaluation.

The injury demographic contains the minimal amount of documentation needed for a patient’s injury. The injury evaluation is a more detailed evaluation that allows for complete documentation of all evaluation findings. NOTE: We recommend utilizing both the injury demographic and the injury evaluation for the most complete documentation for your practice.

To add a new injury for the patient, click on the drop down menu to the right of a patient’s row. From the menu, select Add New Injury.

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This will direct you to the "Injury Demographic" form:

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The injury demographic is a simple form to capture information for a patient’s injury. It is not meant to be a complete evaluation. Within this form you will complete the necessary fields according to your evaluation findings.

#### Included Fields

\*Includes sport participated or activity including industrial worker, recreational worker, and military personnel.

***Some fields within the patient demographic are dependent upon others. For example, the preliminary diagnosis cannot be selected until after the body part injured is selected.***

Once the injury demographic is completed, there are several options for proceeding.

1. Save for Later: save the current injury demographic form for completion at a later time.
2. Lock and Submit: submit completed demographic form and return to Injury Menu. NOTE: once the injury demographic form is submitted, it cannot be edited.
3. Lock and Submit and Continue to Outcomes: submit completed injury demographic form and proceed to outcomes instruments related to the injury for immediate patient completion.
4. Cancel: discard the current injury demographic form and return to the Injury Menu. NOTE: no information will be saved.

 If you would like to add additional outcome instruments to your patient documentation, you can select these in the Injury Demographic form.

The Actions menu can also be used to add a new injury for a patient. This button is available on any patient

### Injury Evaluation Form

Once the Injury Demographic Form has been completed, a region-specific Injury Evaluation Form will be auto-populated in relation to the diagnosis indicated by the clinician. Region-specific forms will include drop-down menu items for range of motion, special tests, manual muscle tests, and neurological screening associated with the injured body region. These region-specific forms were developed to improve efficiency and ease of documentation for clinicians.

To complete an Injury Evaluation form, select an injury for the patient from the Injury Menu. Click on the “Add Injury Evaluation” button above the center window.

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***You must first complete an Injury Demographic for the patient's injury before you can complete an Injury Evaluation.***

Following the traditional documentation format, the clinician can first enter a detailed mechanism of injury and other clinical findings including: weight bearing status, range of motion, palpation, strength testing, flexibility, neurological testing, functional testing, gait, and special tests, as well as the recommended plan for the management of the injury, timelines for rehabilitation goals, home exercises and instructions, and coding for procedures performed.

Information from the “Injury Demographic Form” is automatically imported into the evaluation form, which reduces the need for double entry, saving time for the clinician.

The majority of the fields within the Injury Evaluation form are drop down menus, which helps to expedite the documentation process and to standardize data. This form will also provide summary information for end-of-season and year reports as well as further efforts to characterize athletic training practice.

Compared to the Injury Demographic form, the Injury Evaluation form is much more comprehensive and provides a complete evaluation template to document all types of injuries.

***Fields with a red asterisk must be completed to submit the form.***

#### Included Fields

 Palpation
 Flexibility tests/Assessment
 Recommended treatment plan

Also included on the Injury Evaluation form are free entry text boxes to add additional information regarding the various clinical tests. This allows the clinician to not only enter standardized data through the drop down menus, but also document any additional findings or information.

 If you choose to have your patient complete the Patient Specific Functional Scale as part of your outcome measures, the specific activities that the patient enters will be included in the goals section of the Injury Evaluation form. This provides an effective way to address patient-specific problems related to their injury adequately.

Once you have completed the Injury Evaluation form:

1. **Lock and Submit**: submit completed injury evaluation form and return to Injury Menu. NOTE: once the injury evaluation form is submitted, it cannot be edited.
2. **Save for Later**: save the current injury evaluation form for completion at a later time.
3. **Cancel**: discard the current injury demographic form and return to the Injury Menu. NOTE: no information will be saved.

### Daily Treatment Form

To complete a Daily Treatment form, from the Patient Injuries/Forms page, select a specific injury for the patient and then click on the “Add Daily Treatment” button above the center window.

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The Daily Treatment form provides the athletic trainer with the ability to document daily rehabilitation activities and subjective information for the patient. Basic information on the status of the injury is imported into the form automatically, including the diagnosis, current participation status, time since injury, treatment time, and the patient’s previous numeric pain rating. This imported information is taken from the most recent patient visit, either the injury evaluation or last daily treatment.

Also included in the Daily Treatment form is the status of the clinical outcomes instruments. The Outcomes Scores window gives the clinician information on which outcomes instruments the patient has completed or needs to complete. The “Login as Patient” provides quick access to the outcomes instruments.

***Outcomes instruments are completed at multiple time points (e.g., at initial injury, 10 days post injury, 30 days post injury, and discharge) The Outcomes Scores window will display the current timeline for completing Outcomes Instruments.***

#### Included Fields

 Procedure Summary

When entering exercises into the daily treatment record, provide a description of the exercise, and then enter the duration, frequency, weight, etc. You can use the “Tab” button on your keyboard to move through the boxes. Once you enter a duration/frequency, an additional set of fields will be generated, allowing you to enter as much information as needed.

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The procedure summary fields allow for coding of the specific activities performed during the visit. Utilizing standard Common Procedural Terminology (CPT) codes, you can characterize your treatment activities and provide standardization to the rehabilitation exercises. Codes are provided for the most common procedures utilized by athletic trainers. Standard coding considers one unit to be 8-15 minutes of activity.

For the exercises in the above image, it is be estimated that it would take the patient 15 minutes to perform all three activities, so the CPT code of 97110 – Therapeutic Exercise would be selected, along with 1 unit.

***Depending on the duration of the exercises you may choose 1 or more units.***

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Once you have completed the Daily Treatment form:

1. **Lock and Submit**: submit completed daily treatment form and return to Injury Menu. NOTE: once the injury evaluation form is submitted, it cannot be edited.
2. **Save for Later**: save the current daily treatment form for completion at a later time.
3. **Cancel**: discard the current daily treatment form and return to the Injury Menu. NOTE: no information will be saved.

### Discharge Summary Form

To complete the Discharge Summary form, select an injury from the Injury Menu.

Click on the “Add Discharge Summary” button above the center window.

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The Discharge Summary provides an complete re-evaluation of the patient’s injury, and includes all of the information from the Injury Evaluation form such as weight bearing status, range of motion, general inspection, palpation, strength testing, flexibility, neurological testing, functional testing, gait, and special tests.

It also provides documentation for achievement of goals that were developed with the initial evaluation.

#### Included Fields

 Edema
 Functional tests
 Procedure summary

Once you have completed the Discharge Summary form:

1. **Lock and Submit**: submit completed discharge summary form and return to Injury Menu. NOTE: once the injury evaluation form is submitted, it cannot be edited.
2. **Save for Later**: save the current discharge summary form for completion at a later time.
3. **Cancel**: discard the current discharge summary form and return to the Injury Menu. NOTE: no information will be saved.

### Printing Forms

All completed forms can be printed directly from the EMR.

Simply double click on the desired completed form from the “Form Table”.

Next, find and click on the “Print” button located at the bottom of the completed form window.

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### Outcomes Instruments

The outcomes instruments utilized by the EMR include both generic and region specific outcomes instruments. For each patient’s injury, a generic and (if appropriate) region specific outcomes instrument will be generated for the patient to complete.

Generic outcomes instruments are generated based on the patient’s age, while region specific outcomes instruments are generated based on the body part selected in the Injury Demographic form.

All multi-question outcomes instruments are administered on a specific timeline, with initial completion at the time of injury, first follow up 10 days post injury, and final follow up 30 days post injury and at discharge.

The EMR system is designed to notify both the athletic trainer and the patient when outcomes instruments need to be completed. Athletic trainers receive notification at the completion of the injury evaluation, and can also monitor the status of outcomes forms from the Injury Menu (Patient View) and on the Daily Treatment form.

Patients will receive email notification when outcomes forms are due, and an additional email notification 2 days after forms become overdue.

To view completed patient outcomes instruments, select the injury from the Injury Menu.

Click on the “Patient” button to enter Patient View.

Highlight the selected outcomes instrument, and click on the “View Form” button to the right.

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