Instinctive Notes is built from the ground up to record all the details you need for compliant clinical notes.
Recording the right details
It provides three distinct methods for capturing patient information:
- SOAP Notes for clinical details
- Client Notes for non-clinical details and alerts
- Attachments for documents
Each of these is designed with compliance in mind and provides the components and fields to capture the information you need.
You can find out more on exactly how they work and what they cover in the following guides:
Importantly, with Instinctive Notes you don't need to build any of your own clinical note templates to be compliant.
There's no research on what details you need to capture, no long template configuration that never seems to be able to be flexible enough to meet the requirements and no stress that you've missed something important.
Just compliant notes as soon as you open the app, with some smart customisations to make it work best for you.
Keeping it legible
The second important element of compliance is how well your notes can be understood, both by your future self and anyone else who picks them up.
To be compliant your notes need to be of such a quality that another chiropractor could read and reasonably understand the terminology and abbreviations used and, from the information provided, be equipped to manage the care of the patient.
When building templates you can't always achieve this aim, but Instinctive Notes provides a whole series of features which mean that legibility and understanding are built right in.
Here are some of them.
Codes, pick lists and typing - Not handwriting
The most important feature for legibility and understanding is the use of codes, pick lists and typed notes.
Handwriting can be difficult to understand, may have unknown abbreviations and is not searchable. On all counts it fails the legibility and understanding test.
By codifying abbreviations, using pick lists in the place of general text in most cases, and only using general text notes as a last resort, Instinctive Notes puts legibility and understanding front and centre.
Standard treatment templates
With six standard code templates for capturing treatment details, covering the most popular chiropractic techniques, it is always clear what treatments have been performed during a consultation.
Standard templates include:
- Applied Kinesiology
- ABC Protocol
Additional standard templates can be added to support other chiropractic techniques.
Intelligent custom treatment templates
For those times the standard templates don't fit your personal treatment requirements custom templates can be created.
Building them always has legibility and understanding in mind. Every custom code must have a description which means the same thing across your practice. These descriptions are available to ensure that it's always clear what you meant when you recorded a treatment using a custom template.
With Instinctive Notes custom does not mean understandable only by the practitioner who uses the code.
Standard treatment listings
Instinctive Notes is built on standard listings. Wherever possible standard lists are used to ensure there is no ambiguity in the treatment details you record.
Current standard lists include:
- Complaint categories
- Complaint locations
- Complaint onset triggers
- Complaint onset frequency
- Complaint pain quality
- Test results
- Muscle Extensions
- Limb Extensions
- Home recommendations
Of course, there may be a specific item that you use that isn't included in the standard lists. We are always happy to evaluate requests for change to any of the standard lists, and will add them quickly if they make sense.
Tests are a special standardisation case.
As well as standardising the list of tests, each test has been fully investigated to ensure that the result tracking used is correct. Additionally, a description of each test is provided to assist you when you haven't used a test in a while.
Clear scheduling options
Scheduling future appointments is likewise standardised, with detailed plan scheduling or wellness scheduling available depending on your treatment plan.
Whether you are scheduling week by week or are seeing a patient only once every few weeks, the schedule is clear and unambiguous.
Lastly, each attachment can be up to 10MB in size which is plenty to ensure that the details of any document are legible, a key compliance requirement.
You can store as many attachments as you need, so every document that forms part of the patients file can be stored and is always available.
The right content, always understandable
Instinctive Notes is built to ensure that you can capture all the details you need to have compliant clinical notes.
Each feature is carefully designed with legibility and understanding built in, so at that moment when you need to produce your notes you know not only that you have them, but also that they will be clear and easy to understand.