Record the Visit

  1. From the Inj/Ill Visit screen, click on Patient Description of Injury and type what the patient describes for onset of illness or injury event.
  2. To store the medical chart, use the Progress Notes button. Type chart information and Save.
    Optionally import a template you have designed (such as SOAP format) via File > Open; remember to click your cursor at the end of any existing text to append, rather than overwrite the text.
  3. Save and Exit (Ctrl+S).
  4. Optionally, record Severity of Injury and Level of Pain.
  5. Select ICD (1). Add ICD (2) through ICD (12) if needed.
  6. Determine whether patient can return to work without restrictions. If so, in Clinic Status area type R. If no level of work is possible, type O. If restricted work is possible, type L. In adjacent date field, press F8 to enter today’s date, then the plus key (+) on the keypad to increase by one day (used for L or O status, which begins the following day).
    This activity automatically generates a checkmark in the CM Review field so that the case manager can follow up. If you do not wish to have the case manager involved, uncheck CM Review. Create a message to the case manager via CM Memo.
  7. If L was used in the Clinic Status, or if you want to enter any instructions for the patient or company, click Add Work Rest button (Alt+W). Click in the box to the left for any restriction you wish to use. Any restriction that has a P appears on the patient’s portion of the Discharge Summary Report; any restriction with a W appears on the company’s portion.
  8. After adding the work/personal restrictions, edit them as desired by clicking once in the Description for the one you want to change. Press Home to move cursor to beginning, left or right arrow to move cursor one space at a time, or just start typing to erase the entire text and replace it. Edit the Value and Units columns to better fit the restrictions to the patient’s circumstances.
  9. Save (Ctrl+S). Use Close Injury button to close cases when appropriate.
  10. Add additional orders as needed, mark completed orders (Orders Quick Guide).
  11. If the patient’s name should not appear on the OSHA 300 due to privacy concerns (HIV, mental illness, sexual assault, etc.), go to Injury screen and check the Privacy Case field.
    This causes the wording “Privacy Case” to appear on the OSHA 300 Log.