Treatment

The Treatment screen is used to record details about a patient visit for a specific injury/illness. The information can also be entered using appropriate PDF forms attached to orders.

Once the patient has arrived, be sure to change the status of the appointment from A to T in the C/A/N/T field. This happens automatically if you use Scheduling.

Each treatment visit is given a separate record and together make up a complete history of the care of the injury. While it is possible to create a new appointment via the Treatment screen, instead use the Appointments module. Please note that appointments made via the Treatment module are not created simultaneously in the Appointments module. Once the treatment regimen is complete and you no longer need to see the patient for this injury, you can close the case.

Note: If there is more than one injury for the patient, be sure you are working on the correct one. Use the list view to see all the injuries for the patient.

Label	Description
Injury ID	Check to ensure you are working on the correct ID for patients who may have more than one injury record.
Tr ID	SYSTOC automatically increments the treatment number.
C/A/N/T	Each record in this table is used twice: first to show the appointment and second to record the results of that appointment – the actual treatment. When a patient keeps her/his appointment, do not create a new record to document the treatment, just change the code from `A` to `T` in the C/A/N/T field. If an appointment is missed without explanation, change the `A` to an `N` to indicate a no-show. If the appointment is canceled for a valid reason, change the `A` to a `C` to indicate canceled. Explain the circumstances such as cancel or no-show in the Comment field. All these changes can also be made on the Appointment Register and will copy to the treatment record automatically.
Treatment/Appt Date	Date of the appointment or treatment session.
Time	Time (24 hour) of the appointment.
Staff ID	Medical Staff person who worked with the patient (may be different from primary physician).
Treatment	If the record is an appointment, describe the activities planned. If the record is a treatment, describe the treatment session. For more detailed reporting, you can use the F3 Memo (see F3 Memo on the Treatment Screen).
ICD Codes (1) through (12)	Add or edit ICD codes on this screen.The first ICD code is the primary diagnosis. Click Lookup to search by criteria such as Code, Description, or Trauma. ICD codes on Treatment update Injury when the Treatment screen is saved with a status of T and a code in ICD (1). See exception below: When a saved treatment with a status of T has a Rehabilitation Treatment Code, the ICD codes on Injury are not updated. Also see Tap2Chart section below. When a treatment is added from Treatment and there are ICD codes on the Injury screen, a query asks if you want to copy diagnosis codes from Injury for the treatment. When an appointment is added or copied from the Schedule Grid, Appointment Register, or Clinical Work Area , the ICD codes from the copied appointment populate the new Treatment record from Injury. Note: Remove the ICD codes from the copied visit if you are creating an appointment for a new injury. The ICD code set that is presented on lookup is determined by the setting and date on Program Preferences. Tap2Chart: A saved Tap2Chart note containing a diagnosis section saves the ICD codes to Treatment. Injury is updated only if the note is associated with the last treatment with a status of T. A saved Tap2Chart note does not update the SYSTOC Physician Diagnosis memo and ICD codes on Injury from Treatment when: (a) the note is associated with a SYSTOC order with an appointment type of Rehabilitation, and (b) the SYSTOC treatment has a Rehabilitation Treatment Code and is the latest saved treatment with a status of T.
Cl Status	Work status from the clinic's point of view: `R` for Regular Duty `O` for Out of Work `L` for Limited Duty, or leave blank This code is used to report lost days to the company. If you enter a clinic status, you must enter an effective date in the adjacent field. Normally this is the next workday after the present visit, but the physician may specify another date.
Co Status	Work status from the company's point of view: `R` for Regular Duty `O` for Out of Work `L` for Limited Duty, or leave blank This may differ from the clinic's version if the company has no limited duty jobs available. Enter effective date in the adjacent field.
Treatment Code	Link to File Maintenance > Setup - Injury > Appointment Types to select a code that describes the type of visit, such as `ANN` for Annual Physical Examination. To make a referral to another doctor, enter `REF`. A `REF` code on an `A` record (C/A/N/T field) is picked up by reports that count your referrals and is used to generate a form letter for the physician who receives the referral. When a treatment with a Rehabilitation Treatment Code is saved (the latest saved treatment with a status of T), the Physician Diagnosis memo and ICD codes on Injury and Injury/Illness screens are not updated.
Location ID	Link to File Maintenance > Clinic Locations to select the correct facility where patient is being treated.
Case Mgr ID	ID of the person managing this case.
Referred By	For referrals, enter the ID of the physician making the referral in this field and make sure `REF` is entered in Treatment Code. See Making Referrals and Deciding to Close the Injury).
Level of Pain	Indicate patient's pain level from `0` (no pain) to `10` (extreme pain).
Physical Capacity	What is the patient's physical capacity? `S` (Sedentary Duty), `L` (Limited Duty), `M` (Medium Duty), `H` (Heavy Duty), or leave blank.
Able to Grasp	Is the patient able to grasp objects? `Y`, `N`, or leave blank.
Able to Manipulate	Is the patient able to manipulate objects? `Y`, `N`, or leave blank.
Auth ID	SYSTOC numbers each Authorization ID incrementally. If you come to this screen from the Treatment Authorization screen, Auth ID, Type of Serv, AuthCode, and Auth By fields are filled in automatically. Otherwise, navigate to InjuryFolder > Authorizations to select the ID. Leave blank if the treatment is not linked to an authorization.
Type of Serv	Link to File Maintenance > Setup - Injury > Treatment Type of Service to select the appropriate unit. If you come to this screen from the Treatment Authorization screen, this field will auto-fill.
Auth Code	Is the same as the Begin Number from the authorization table. If you come to this screen from the Authorization screen, this field will auto-fill.
Auth By	Link to File Maintenance > Staff to choose the person who authorized the treatment. If you come to this screen from the Authorization screen, this field will auto-fill.
Transcription Approved	Check if the transcription of the treatment has been approved for viewing by client companies or insurance providers via iSYSTOC.
Comment	What you type here appears in the Injury Management Report that is sent to the company; use it to flag important information.
Work Restriction
Add Work Restriction(s)	Opens Work Restrictions table. See Work/Patient Restrictions.
Remove Work Restriction(s)	Removes Work Restrictions from the list.
Work Capacity Notes	Click (or press Alt+N) to access a memo editor where you can store work capacity information as a narrative. Normally this memo is not accessed directly, but instead is completed via the Tap2Chart form. This is not the place to store the medical record that will go to the employer and insurer. For that, use the F3 Memo. For another method of recording work capacity, see Work/Patient Restrictions.