Spinner

When you first start up your agency you will likely have many clients with a paper chart. To transition to EMR-Bear it is useful to load some of this information into EMR-Bear. It is recommended that you create a transition form to facilitate this process. Let's create a form called Data Entry Addendum with the following models.

  • Form Introduction
  • Demographic Information
  • Symptoms & Problems
  • Goals, Objectives, and Interventions
  • Allergies
  • Program Referrals
  • Diagnosis
  • Signature

The following steps should be used when preparing a client's file in EMR-Bear:

  1. Complete a Data Entry Addendum form. The purpose of this form is to record the most current clinical data for existing clients, taken from the most up-to-date clinical documents completed for that client (i.e. recording the client’s problem list from the most current Assessment, recording current goals, objectives, and interventions from the standing treatment plan, or recording the client’s clinical diagnosis.). Note that, because the purpose of this form is to transcribe current clinical data from the client’s current chart into EMR-Bear, the clinicIan SHOULD NOT use the suggested goals, objectives and interventions provided by EMR-Bear in the GOI model, but rather use the "other options" link below those pull-downs to type in GOIs verbatim from the paper treatment plan.

  2. Update Documentation Tracking dates in the client's file tab using the "previous form" link to note the date of the paper version of these documents in the paper chart. For example, next to "Treatment Plan", use the "p" link to input the date of the last treatment plan done on paper.

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  1. On the client's Admin tab, verify that the referral and enrollment dates are accurate according to the paper chart. To edit those dates, click on the name of the program you're editing dates for and enter accurate dates in the enrollment window.

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