Insight GO Quick Links
Supervisory Visits
Supervisory Visits include Initial Evaluations, Progress Reports, Re-Certifications of the POC and Discharge Summaries. The steps apply to both "face to face" visits and also "paper reports". In addition to the required components described under Charting Basics, the following additional steps are required:
​
-
Establish / Update Patient Goals
-
Add POC Date & Progress Report Due Dates to System for tracking
-
Add Diagnosis to Case
-
Add Onset Date/Signature Date/Admit Date
Page Links
INITIAL EVALUATIONS
Charting the Initial Evaluation is the most complex task as it requires additional data entry for Diagnosis and Plan of Care to create the framework for the patient's therapy plan. The following are the steps:
​
-
Schedule and arrive the patient for an Initial Evaluation Visit Type.
-
Add Template for Initial Evaluation for your discipline
-
Complete documentation and create goals.
-
Enter "Details" including Onset Date, Signature Date, Diagnosis and Plan of Care.
-
Audit and sign off.
Setting Goals
When charting a patient visit, InsightGO allows you to mark any line item as a goal for tracking. To set an item as a goal, right click or click and hold on the Item Name and choose "Make This a Goal"
This will open a Goal Information box where you can enter goal information. "Current Goal" is obtained from the data entered into the evaluation or most recent chart note. Desired goal state can be selected from Options if available or through free text. Also enter the "Goal Due Date" and then click/tap "Apply".
ADD PATIENT DETAILS
At the time of the Initial Evaluation (and at each supervisory visit or discharge visit) case details need to be entered. Case Details are accessed first by expanding the Patient Details field and then selecting the case name. In this example, I have selected the PT Case. Items highlighted in yellow are what needed to be added at the Initial Evaluation.
Date of Onset = Date the condition started or declined
Signature Date = Date Intake was completed (enter if you completed intake paperwork with patient).
Admit Date = Date of Initial Evaluation
Diagnosis - Click on the + sign to add diagnosis to case and search by ICD-10 Code or by descriptor.
Adding POC/Progress Report
Scroll down to the Plan of Care section and click the "+" Sign to Add Plan of Care/Progress Report. At Initial Evaluation or for a Re-Certification, Choose "Plan of Care" which adds both a Certification Period and also Progress Report. System will default to current date of service and Medicare allowable certification period and # of Visits until a Progress Report is needed. At the time of a Progress Report, just choose "Progress Report"
Click the "Save" Icon at the top right to save your changes and return to the Chart Note.
PROGRESS REPORT
The steps for a Progress Report are the same as for any other visit but also require the therapist to Update Patient Goals and Add Progress Report to Patient Details section to reset visit count.
​
-
Schedule/Arrive the Patient
-
Load Chart Template for a Progress Report (with or without re-certification)
-
Update Patient Goals
-
Add Progress Report to Patient Details Section to re-set visit count for a Progress Report
-
Add both POC & Progress Report for a Re-Certification
DISCHARGE
Discharge Steps
​
-
Schedule/Arrive the Patient
-
Load Chart Template for a Discharge Report
-
Update Patient Goals
-
Change Patient Status from Active to Discharged on Patient Details Screen
-
Enter Discharge Date & Reason on Patient Details Screen
PAPER REPORTS
Non-visit / Paper Reports provide documentation for a patient even when the patient is not seen. For example, a patient who was discharged to HH may need a "paper" report only. The steps are identical to creating any other report, but please make sure your Procedure Time/Minutes is set to "0" so that a bill is not generated.