Notes Section of EMR

It is important to document whether the appointment visit was completed OR if a patient had a missed visit and state the reasons why. For every week that a patient does not complete their recommended POC sessions, there should be a corresponding note for the reason why. If that chart gets pulled a year from now we won't have those details unless you document them.

Each week you should be writing your documentation OR writing a note why pt not seen. Reasons can be the therapist's vacation, the patient being out of town, medical concerns, pt forgetting, and so on..

Follow these steps to document a note in the patient chart:

Find the patient chart in Insight Go

Go to Notes

Click the Orange Create button to create the note to complete