Clinical Notes
We believe the flexibility and efficiency of entering clinical notes in VisitBase sets it apart from our competitors. Scroll down for details of some of our best features.
Clinical Notes Overview
- Create services for any treatment modality
- Customise clinical note short-cuts for different practitioners or share the same short-cuts
- Easily scroll through past clinical notes
- Configure different privileges for different staff
- Add scanned documents, photos or other files as attachmentss
- Record audio, video or take photos directly in patient file on an iPad or iPhone
- Take questionnaires directly in the patient file
- Rate key signs and symptoms and graph changes
- Use templates to create letters in a flash
- Use our integration with Physitrack®
- insert your own home care recommendations into the patient file
- Draw or Markup images
Clinical Note Shortcuts
Create hundreds, or even thousands of clinical note shortcuts to streamline data entry during a consultation. A shortcut is basically a button that will insert anything from a few letters or a number, to an entire paragraph or history and examination routine, into the clinical notes.
The shortcuts are arranged in numerous selectable groups and can be organised by their relevance to a particular condition, patient type, body region, assessment component, treatment technique or therapy style. Each practitioner can have their own set of these shortcuts, or they can be shared amongst practitioners.
Our shortcut feature is aimed at significantly reducing the amount of typing required by the practitioner. However, there is no effort required to switch between using these buttons, typing, or using dictation (such as the built-in text-speech conversion option on iOS devices). The simplicity and time-saving nature of our clinical notes system is of great value to practitioners on both computers and iPads.
Consultation Templates
Similar to our clinical note shortcut feature, consultation templates are highly customisable. A consultation template comprises predefined content based on the modality that the practitioner is linked to (e.g. Chiropractic, Physiotherapy, Massage etc), the service type that the consultation record is linked to (e.g. Standard, Review or Initial Consultation), or even the individual patient.
The template is inserted into the clinical notes automatically when the consultation record is created, therefore providing a helpful guide for the practitioner depending on the context of the appointment. The practitioner can then add further content to the clinical notes as required.
Documents and other Attachments
Reports, scanned documents, photos and other attachments can be easily added to the patient file, and will appear as thumbnails that can be expanded when required. Common file formats such as PDF, JPEG, MOV, WAV, can be previewed directly in the VisitBase patient file, while other formats will open externally using the default application for that file format on the user’s device. This offers convenience for quick review of previous X-rays, other imaging or reports.
For practitioners using an iPad in the consultation room, photos, video and audio recordings can be added to the patient file without leaving the VisitBase application. In addition, practitioners can draw on or markup a photograph or a template image within the patient file.
All attachments are encrypted at rest and in transit to ensure the data is secure.
Questionnaires
Questionnaires (also referred to as Scales or Forms) can be sent to patients to complete online via an email or sms link. There is no need for creating separate accounts or integrating other software, as our online form system is built directly in VisitBase. This allows users to meet privacy and data residency requirements as you can be assured that the patient data is stored in the same data centre.
Questionnaires can be created and customised within VisitBase. This includes the ability to change the response options and styles, such as radio buttons, checkboxes, text fields, text areas, drop-down lists and signature areas. You can also customise section headings and headers to better match your clinic website.
Results submitted by patients will appear in their file. Practitioners can also view comparisons between previous results of the same form either as a chart in the patient file, or by running specific reports from the stats area.
Rating Signs and Symptoms
Often a practitioner will ask a patient to rate their pain or another symptom as a simple way of tracking their symptoms and progress over time, and to gauge the current perception of their health problem. VisitBase provides a specific feature for keeping track of any key sign or symptom, whether it is rated subjectively by the patient, or objectively by other means (e.g. electrophysiological testing, ROM goniometer, or established rating options for strength, reflexes or other findings).
Rather than completing a full questionnaire, it only takes a few seconds for the practitioner to add entries for one or more key signs and symptoms, and then view a chart of progress over time with the click of a button. The same feature can be used for monitoring raw values, percent values, variations between two values (e.g. left versus right), body mass index or blood pressure, depending on the calculation type that is selected.
Letter and Report templates
Similar to how consultation templates and clinical note shortcuts can be customised, letters or reports can also be generated in the patient file using customisable templates. The templates can include variables that pull information from almost any area of the patient file. As an example, a template could allow the insertion of information from the most recent consultation record, the case overview field, name and DOB, and a list of current home care recommendations. It can also include information related to third party claims, such as claim numbers and date of referral etc.
Once generated from a template, a letter can then be saved as a PDF document, emailed or printed.
Home Care Recommendations & Rehab
Having a dedicated home care section in VisitBase allows the practitioner to easily find the patients current (as well as previous) home care recommendations (exercises, nutrition, advice) and rehab programs, without having to scroll through copious clinical notes. Practitioners can add their own custom home care items along with photographs, and if they have a Physitrack account, they can import rehab programs from there.
Home care items can also be combined into “Protocols” so that practitioners can select one protocol with multiple linked exercises or nutritional recommendations. Adding home care recommendations to a patient file can also simplify billing, as products that are recommended by the practitioner can appear on the invoice window, ready to be added by staff.
Integrating Physitrack into VisitBase can simplify the prescription and monitoring of home exercise programs for your clients. Exercise programs can be inserted as a PDF attachment into VisitBase and synchronised with the ‘Home Care’ section of your client record. You can also open and create client records, and add programs in Physitrack, directly from VisitBase.
Physitrack lets you…
- Prescribe stunning exercise programs
- Track client outcomes in real-time (incl. 60+ outcome measures)
- Educate clients through 3D anatomical animations
- Have secure Telehealth video calls with your clients
Assigning Privileges
Security is our number one priority, and one important security principle is that privileges should only be granted on a need-to-know or less-is-best basis. If your business has multiple practitioners of different modalities, you can customise their privileges by creating access groups. Access groups define which consultation records a user will be able to view. Some users may be able to view consultation records created by several different access groups, while others may only be able to view records created by their own access group.
This feature can enhance privacy and prevent unauthorised access along with many other security features offered with VisitBase.