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Registering a new patient
Registering a new patient
To register a new patient, click on the “Register New Patient” button in the top left of the AT Dashboard (shown below).
This will direct you to the patient registration form. On the patient registration form, complete the fields with the patient’s personal demographic information.
Fields with an * are required in order to submit the form.
Patient Username and Password
Patient Username and Password
The patient username is the personal patient id that your patient will use to access the system from home.
It should be something simple to remember and unique to each patient.
We recommend using a standard system for all patients, such as first initial, last name, or first name, last initial.
John Doe = jdoe or johnd
You cannot register two patients with the same username. If a username is already in use, the form will submit but the patient will not be available within the patient list window.
Primary Care Physician, Guardian 1, and Guardian 2 information is not required for patient registration, but is recommended for complete documentation.
Once all of the required fields are completed, complete the captcha and click on the "Submit" button to register the patient. You will be returned to the AT Dashboard, and your newly registered patient will be available in the Patient List.
Daily Log-in
Daily Log-in
The Daily Log-In is a tool for documenting all patients who receive care in the athletic training room. This system feature was created to capture services that may not usually require an injury evaluation or other documentation. It can also be used to track the number of new evaluations, treatments, and other daily practice activities rendered to a patient by an athletic trainer on a weekly, monthly, or even yearly basis.
When entering the athletic training room for care, the athlete will log into the system and select the reasons for their visit. The daily login portion of the EMR functions independently from the Athletic Trainer portion of the system, so both can be opened simultaneously.
Note: A patient must already have his/her name and demographic information registered in the system to utilize the “Daily login” feature.
To reach the Daily Login from the AT Dashboard, click the “Daily Login Page” button in the upper right-hand corner of the screen. This action will log you out of the Athletic Trainer role within the site and open the Daily Login Homepage.
A patient must already have his/her name and demographic information registered in the system to utilize the “Daily login” feature.
Once on the Daily Login Homepage, the patient will type in his or her first name, middle initial, and last name, OR patient “username”
Once the patient logs in with his/her name or already registered ‘username’, he/she will be redirected to a new window. This page captures the following information regarding the patient’s care for the day:
1) A reason for the visit: (New Injury, Current Injury, Prevention)
2) Current Sport or Activity
3) Body Part
4) Side of Body
5) Services being provided: (ie. treatment, evaluation, taping, ice pack / hot pack, wound care, other.)
Once complete, the patient can then “Submit” his/her information. For security purposes, once a patient completes and submits his/her daily login information, the system is redirected to a blank daily login page for the next patient to login.
In order to ensure that all information entered by patients is accurate, clinicians can log into the system and edit the daily login page as needed.
To monitor and adjust the accuracy of the daily login page:
1) Login to the EMR website (www.core-at.com) using the “Athletic Trainer” tab.
2) Once on the main page, you will click on the button labeled “View Daily Logins”.
3) On the daily login page, you will see a list of all patients who logged into EMR system. The default time range is for the current day.
This “patient window” provides a quick look at all patients who logged into the system during the selected time frame. From this list you can see patient names, sports, services selected, and the date of login. In addition, the right hand column indicates whether the login record has been locked from editing.
4) To view detailed information about the patient’s login, click on the row containing the patient’s entry.
5) You will now see the detailed information that the patient entered into the system. This includes the reason for visit, body part, side of the body, sport, and selected services. Here, you can modify body part injured, side of body, type of treatment, and the patient’s sport.
Navigation Tips
Navigation Tips
On the daily login page, if the patient enters “new injury” for the reason of the visit, he/she will be granted access to the injury demographic form. Access to the injury demographic form will enable him/her to complete the necessary documentation and return directly to the login screen. If the patient enters “current injury”, the system will attempt to match the injury based on the body part entered. If the system can match the injury, then it will provide a link to a daily treatment form, which allows the clinician to complete the necessary documentation at a later time.
6) Before “locking” the patient’s login information, you must first complete the patient’s injury demographic form or daily treatment form, depending on what service was provided on a given day. If these forms are not completed before “locking” the patient’s login information, the program will be unable to link the patient’s login with the injury demographic or treatment forms.
7) Once these forms are complete, to confirm that the patient’s information is accurate, you will check the box labeled “Is locked” and click “Update” to secure the information.
8) Once the patient’s login information is locked, you will notice that the right hand column now reads “Locked”. You will no longer be able to make future changes to the information.
Another feature of the daily login page is the ability for the clinician to track the number of patient visits, treatments, new injuries, evaluations, etc. This feature can be accessed by clicking the “View Totals” box at the bottom, center aspect of the screen.
Additionally, if you would like to track patient visits over a specific period of time, you can adjust the “start” and “end” dates at the top of the page. This tool can be used to track daily, weekly, monthly, or even yearly services rendered to a patient by an athletic trainer.
Injury Demographic Form
Injury Demographic Form
An injury demographic must be completed in order to access the other documentation forms within the system.
The EMR system’s injury documentation format is broken down into two steps - the injury demographic and the injury evaluation.
The injury demographic contains the minimal documentation needed for a patient’s injury. The injury evaluation is a more detailed evaluation that allows for complete documentation of all evaluation findings. NOTE: We recommend utilizing both the injury demographic and the injury evaluation for the complete documentation for your practice.
There are two ways to add a new injury for a patient.
From the homepage :To add a new injury for the patient, click on the drop-down menu to the right of a patient’s row. From the menu, select Add New Injury.
From the patient dashboard: Select the actions drop down to the right of the last encounter date. From the menu select "Add new Injury"
This will direct you to the "Injury Demographic" form
The injury demographic is a simple form to capture information for a patient’s injury. It is not meant to be a complete evaluation. Within this form you will complete the necessary fields according to your evaluation findings.
Included Fields
Included Fields
Height
Weight
Date of Injury
Date of evaluation:
Sport or Activity*
Position
Level
Injured During
Simple Mechanism of injury
Time of injury
Body Part Injured
Side of Body
Initial Pain Description
Numeric Pain Scale
Current Participation Status
Previous History of Injury
Other Health Conditions
Preliminary Diagnosis
Severity of Injury
Initial Plan of Action
*Includes sport participated or activity including Industrial Worker or Recreational Athlete
Once the injury demographic is completed, there are several options for proceeding.
1. Save for Later: save the current injury demographic form for completion at a later time.
2. Lock and Submit: submit completed demographic form and return to Injury Menu. NOTE: once the injury demographic form is submitted, it cannot be edited.
3. Lock and Submit and Continue to Outcomes: submit completed injury demographic form and proceed to outcomes instruments related to the injury for immediate patient completion.
4. Cancel: discard the current injury demographic form and return to the Injury Menu. NOTE: no information will be saved.
Clinical Outcomes Instruments
Clinical Outcomes Instruments
Clinical Outcome instruments are utilized within the EMR as part of the overall patient documentation.
For each patient, 2 outcomes instruments will be generated automatically. Patients, who are 18 years old and younger, will complete the PEDS-QL survey. Patients, who are older than 18 years old, will complete the SF-12.
In addition to the general instruments, a body part or region specific instrument will be generated. This will be dependent upon the body part injured.
If you would like to add additional outcomes instruments to your patient documentation, you can select these in the Injury Demographic form.
Injury Evaluation Form
Injury Evaluation Form
Once the Injury Demographic Form has been completed, a region-specific Injury Evaluation Form will be auto-populated in relation to the diagnosis indicated by the clinician. Region-specific forms will include drop-down menu items for range of motion, special tests, manual muscle tests, and neurological screening associated with the injured body region. These region-specific forms were developed to improve efficiency and ease of documentation for clinicians.
To complete an Injury Evaluation form, select an injury for the patient from the Injury Menu. Click on the “Add Injury Evaluation” button above the center window.
You must first complete an Injury Demographic for the patient’s injury before you can complete an Injury Evaluation.
Included Fields
Included Fields
Diagnosis
Detailed Mechanism of Injury
Weight Bearing Status
Active Range of Motion
Passive Range of Motion
Palpation
Effusion
Edema
Ecchymosis
Strength Tests
Flexibility Tests / Assessment
Neurological Testing
Functional Tests
Gait Analysis
Special Tests
Recommended Treatment Plan
Home Exercises Instructions
Procedure Summary
Goals
Social Determinant of Health card
Also included on the Injury Evaluation form are free entry text boxes to add additional information regarding the various clinical tests. This allows the clinician to not only enter standardized data through the drop-down menus but also document any additional findings or information.
Patient-oriented goals
Patient-oriented goals
Included in the Injury Evaluation form are several stock goals related to objective measurements of function – i.e., pain rating, range of motion, strength, and balance.
Also included are goals for the region specific outcomes instruments. This goal is generated based on the patient’s initial score on the outcomes scale and then adding the minimum change in score to indicate clinical relevancy.
If you chose to have your patient complete the Patient Specific Functional Scale as part of your outcomes measures, the specific activities that the patient enters will be included in the goals section of the Injury Evaluation form. This provides an effective way to adequately address patient-specific problems related to his/her injury.
Once you have completed the Injury Evaluation form:
1. Lock and Submit: submit completed injury evaluation form and return to Injury Menu. NOTE: once the injury evaluation form is submitted, it cannot be edited.
2. Save for Later: save the current injury evaluation form for completion at a later time.
3. Cancel: discard the current injury demographic form and return to the Injury Menu. NOTE: no information will be saved.
Daily Treatment Form
Daily Treatment Form
To complete a Daily Treatment form, from the Patient Injuries/Forms page, select a specific injury for the patient and then click on the “Add Daily Treatment” button above the center window.
The Daily Treatment form provides the athletic trainer with the ability to document daily rehabilitation activities and subjective information for the patient. Basic information on the status of the injury is imported into the form automatically, including the diagnosis, current participation status, time since injury, treatment time, and the patient’s previous numeric pain rating. This imported information is taken from the most recent patient visit, either the injury evaluation or last daily treatment.
Also included in the Daily Treatment form is the status of the clinical outcomes instruments. The Outcomes Scores window gives the clinician information on which outcomes instruments the patient has completed or needs to complete. The “Login as Patient” provides quick access to the outcomes instruments.
Outcomes Instruments are completed at multiple time points (e.g., at initial injury, 10 days post injury, 30 days post injury, and at discharge). The Outcomes Scores window will display the current timeline for completing outcomes instruments.
Included Fields
Included Fields
Current Numeric Pain Rating
Overall Condition of Injury
Notes
Exercises
Procedure Summary
Recommendations
Global Rating of Function
Global Rating of Disability
When entering exercises into the daily treatment record, provide a description of the exercise, and then enter the duration, frequency, weight, etc. You can use the “Tab” button on your keyboard to move through the boxes. Once you enter a duration/frequency, an additional set of fields will be generated, allowing you to enter as much information as needed.
The procedure summary fields allow for coding of the specific activities performed during the visit. Utilizing standard Common Procedural Terminology (CPT) codes, you can characterize your treatment activities and provide standardization to the rehabilitation exercises. Codes are provided for the most common procedures utilized by athletic trainers. Standard coding considers one unit to be 8-15 minutes of activity.
For the exercises in the above image, it is estimated that it would take the patient 15 minutes to perform all the activities, so the CPT code of 97110 – Therapeutic Exercise would be selected, along with 1 unit.
Once you have completed the Daily Treatment form:
1. Lock and Submit: submit completed daily treatment form and return to Injury Menu. NOTE: once the daily treatment form is submitted, it cannot be edited.
2. Save for Later: save the current daily treatment form for completion at a later time.
3. Cancel: discard the current daily treatment form and return to the Injury Menu. NOTE: no information will be saved.
Discharge Summary Form
Discharge Summary Form
To complete the Discharge Summary form, select an injury from the Injury Menu.
Click on the “Add Discharge Summary” button above the center window.
The Discharge Summary provides an complete re-evaluation of the patient’s injury, and includes all of the information from the Injury Evaluation form such as weight bearing status, range of motion, general inspection, palpation, strength testing, flexibility, neurological testing, functional testing, gait, and special tests.
It also provides documentation for achievement of goals that were developed with the initial evaluation.
Included Fields
Included Fields
Weight Bearing Status
Active Range of Motion
Passive Range of Motion
Palpation
Effusion
Edema
Ecchymosis
Strength Tests
Flexibility Tests / Assessment
Neurological Testing
Functional Tests
Gait Analysis
Special Tests
Goal Achievement
Plan of Action
Procedure Summary
Global Rating of Satisfaction
Once you have completed the Discharge Summary form:
1. Lock and Submit: submit completed discharge summary form and return to Injury Menu. NOTE: once the discharge summary form is submitted, it cannot be edited.
2. Save for Later: save the current discharge summary form for completion at a later time.
3. Cancel: discard the current discharge summary form and return to the Injury Menu. NOTE: no information will be saved.
Printing Forms
Printing Forms
All completed forms can be printed directly from the EMR.
There are two ways to navigate to print a form.
You can click on the view form button on the patient dashboard. Then find and click on the “Print Friendly” button located at the bottom of the completed form window.
2. You can click the dropdown next to the form you would like to print and select "Print/PDF view"
Once you have the form you would like to print you can click either the "save as PDF" button or "print" button to save or print directly from your web browser.
To print the entire patient record you can select from the actions button on the patient dashboard "Print Entire Patient Record"
You will be taken to a page that lists all of the patient's injuries. You have the option to print all of the forms associated with the patient or only a select few. Once you have selected the forms you would like to print the system will generate the PDF's/ Pages.
Once all the forms have loaded you will be able to save the forms as a PDF or print them.
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