Setting Up PPS Clinical Notes - Lookup Tables

Add
Look this up under the type of new record you want to add – e.g. Client - Add or Appointment - Add

Client
Client records are the hub of your PPS database. PPS refers to these records as “Clients” rather than “Patients” because PPS is used across a variety of business and clinical disciplines, some of whom use the term “client” and others use “patient”. A client record can have either minimal details entered, such as first name and surname, or can be a comprehensive range of details including full address/contact details, alternative addresses, DOB, sex, “known as”, full profile details including “source of introduction”, occupation (plus a range of entries you can set up yourself). In addition you can associate a variety of third-parties to clients such as doctors, insurance companies, etc. The more comprehensive the details you store for each client, the greater the opportunities to use these details in your reports and mail-merge operation. For example, by recording the “source of introduction” for each client (such as yellow pages, local advert, recommendation, etc.) you can run almost any report in PPS to show a breakdown by “source of introduction”, for example “practice revenue” by “source of introduction” will show where you earn the most money from – thus where you should concentrate most on your advertising!

Clinical Notes
The Clinical Notes facility in PPS is available in the “Professional” version of PPS. This includes screens to record your Clinical Notes, manage Treatment Episodes, complete specific forms (Custom Forms) including body charts and your own questionnaires, etc. All Clinical Notes are structured into the framework of Treatment Episodes. Although some of you may be used to slightly different terminology, PPS uses “Treatment Episode” to define a specific course of treatment for a specific condition, and “Consultation” as the individual treatment sessions/consultations. Therefore each time you see a client – whether or not it is an initial consultation/assessment or a follow up treatment – this is known as a “Consultation”. You can have more than one current Treatment Episode per client if required. When you select to record clinical notes, PPS checks to see if there are any current (not completed) Treatment Episodes for the client. If there is more than one, you can choose which one to record your consultation notes for. Otherwise a new Treatment Episode will be started, and this consultation will be consultation number one for the new Treatment Episode. When you complete the consultation, you can enter set up the full details of the Treatment Episode including the name, number of consultations required, diagnosis details etc. See: Treatment Episode for more details. For more detailed information about recording clinical notes and consultations, see: various entries under Consultation and Custom Forms.

Code
See: Charge – Code; Diagnosis Code; Outcome Code

Company
Company is the “company name” element of a Third Party contact (as opposed to contact name). Third-party Contacts are individuals or organisations that can be associated with clients, for example Insurance Companies. You are able to set up your profile of third-party contacts yourself using the option from the PPS Menu: Tools – Options, and selecting the Client Contacts tab. Each type of contact (there are 9 in total) can be referred to via contact name, and Company name. An example is a Law Firm, where Contact Name would be an individual lawyer or solicitor, and the company would be the law firm.

Consultation
PPS uses the term “consultation” to define each time you see a client, whether or not it is an initial session, or a follow up one. PPS has a clinical notes system that allows you to record Consultation notes each time you see a client, and these are all part of a Treatment Episode. If you see a client once, and their treatment is completed in one consultation, then the Treatment Episode will only have one consultation. If, alternatively, you see a client six times before the treatment for the presenting problem is complete, then the “one” treatment episode will have “six” consultations. To access the clinical notes system in PPS, either select from the PPS Menu: Client – Consultation, or click Consultation on the PPS Task bar. You can select an appointment, or client record first if required to give immediate access to the consultation screen for that client.

Create
See: Add; Charge – Create

Delete
Delete is the term used to remove any record or file in PPS. Most “data entry” type screens will include a Delete button on the toolbar. You can use this button to delete the currently displayed record. There are various restrictions placed on deleting records in certain parts of the system. For example you cannot delete a client record if accounts records exist for that client. The System Administrator can also decide which PPS Users are allowed to delete which type of records. This is set up as part of the User Profile for each user – see: Access Control for more details.

Details
This is a generic term used to describe the information stored in any particular part of PPS. For example Main Client Details is the information you enter to this screen. In addition, there are several “notes” type fields that allow you to enter further “free text” details against a record – these are also sometimes referred to as Details.

Diagnosis
When starting a new Treatment Episode as part of your clinical notes records, you can enter Diagnosis details. This can be useful for reporting purposes to help analyse the type of problems you are treating. There is a “Diagnosis Codes” table where you can set up your standard list of Diagnosis entries. To set up this table, select from the PPS Menu: Tools – Look Up Tables, and select the Diagnosis table from the Clinical Notes section. To make a Diagnosis entry as part of your clinical notes, from the PPS Consultation screen either use the <Update> button towards the top of the screen – this updates the Treatment Episode details for this consultation, or when completing the consultation enter the diagnosis details in the Treatment Episode details screen (can be accessed using the <More> button in section 1) of the Consultation Complete screen. The Diagnosis can be selected as a Breakdown option on many reports – especially clinical notes type reports.

Discharge Status
When completing a Treatment Episode as part of your clinical notes records, you can enter Discharge Status details. This can be useful for reporting purposes to help analyse the type of problems you are treating and their outcome. The Discharge Status will normally be an entry such as: “Treatment Completed”, or “Referred on for alternative treatment”. There is a “Discharge Status” table where you can set up your standard list of Discharge entries. To set up this table, select from the PPS Menu: Tools – Look Up Tables, and select the Discharge Status table from the Clinical Notes section. To make an Discharge entry as part of your clinical notes, from the PPS Consultation screen either use the <Update> button towards the top of the screen – this updates the Treatment Episode details for this consultation, or when completing the consultation enter the Discharge Status details in the Treatment Episode details screen (can be accessed using the <More> button in section 1) of the Consultation Complete screen. The Discharge Status can be selected as a Breakdown option on many reports – especially clinical notes type reports.

GP
See: Contacts – Doctors; Client – Third-Party Contacts

Include
This is a term used in the PPS Reports Wizard – on step 3 of the selections for your report. On most reports you can select to “include” a selection of details on the printed report. You can un-tick any items that you do not want to include. The “Include” options only apply when the report is printed or previewed – if you are exporting the report to a file or mail merge, then the “include” options do not apply.

List
List is the term used to describe information that either appears on the screen or on a report in rows and columns. The term List is also used in PPS as a list of items such as menu, or list of entries such as a look up table. See also: List style diary.

Modify
This is the term used throughout PPS to “change” any of your existing records. PPS has buttons on many screens with a <Modify> prompt. Clicking this button will normally take you onto a further screen that allows you to modify the selected details. For more information about modifying various types of record in PPS, see the “modify” entry under the various section of this help guide, for example Invoices – Modify, Appointments – Modify, etc.

Notes
See: Client - Default Notes Entry

Open
Some screens in PPS have an “Open” button on the toolbar, this is very similar to the Modify button as it will “open” the selected record for “modification”.

Outcome
When completing a Treatment Episode as part of your clinical notes records, you can enter Outcome details. This can be useful for reporting purposes to help analyse the type of problems you are treating. The Outcome will normally describe the clinical outcome to your treatment and will be an entry such as: “Maintenance Achieved”, or “Problem resolved”. There is a “Outcome Codes” table where you can set up your standard list of Outcome entries. To set up this table, select from the PPS Menu: Tools – Look Up Tables, and select the Outcome table from the Clinical Notes section. To make an Outcome entry as part of your clinical notes, from the PPS Consultation screen either use the <Update> button towards the top of the screen – this updates the Treatment Episode details for this consultation, or when completing the consultation enter the Outcome details in the Treatment Episode details screen (can be accessed using the <More> button in section 1) of the Consultation Complete screen. The Outcome can be selected as a Breakdown option on many reports – especially clinical notes type reports.

PPS
PPS is the acronym for “Private Practice Software”.

Print
You can print various types of information in PPS including client details, clinical notes, Invoices, letters, and a wide variety of reports. All printing in PPS is done using your standard Windows printer driver for your selected printer. Many screens in PPS have a <Print> button that is used to print details for that part of the system. See also: Reports – Report Output.

Referral
This is a Look up Table that is used on the Treatment Episode details. The list can be used to help you categorise your sources of referral for each treatment episode in order to make your clinical notes reports more meaningful. You can set up your list of referral sources by selecting from the PPS Menu: Tools – Look up Tables, and selecting Referral from the Clinical Notes Tables section. You do not have to use the Referral entry on your Treatment Episode details if you do not want to. The Referral entry selected for each treatment episode is stored separately to the Source of Introduction on the Main Client Details screen. This is so that you can not only monitor where your clients initially heard about your clinic from , but also where your repeat business comes from.

Reports
PPS includes many different reports that you can run that present information accumulated from various parts of the system. There are two main reports options: Summaries and Statistics, and PPS Reports and Mail Merge. In addition to these two main options, there is a variety of other print-outs that you can produce from PPS that are not included in the category of reports. These include: Printing the Diary, Client Details, Medical History and Clinical Notes. You can access the PPS reports options from the PPS Menu: Reports. For more details about the Statistics & Summaries type reports, see: Statistics & Summaries. When you select the PPS Reports & Mail Merge option, a reports selection screen appears – this screen is divided into the various categories of reports that you can run. Most reports (certainly client-based reports) can also be used for mail merge purposes. Select a report from any of the categories and use either the Run option (see: Reports – Run) or the Open option (see: reports – Open). When you select Open, you will be guided through the Report Wizard (see: Report Wizard) to allow you to make your specific selections for the report before choosing a report output option (see: Reports – Report Output). See also: various entries in this reference guide under Reports for further details. For details of individual reports, see: the entry under the report name, for example Charges Report or Aged Debtors Report.

Revenue
All PPS Accounts records concerned with billing, are part of your practice Revenue. In PPS terms this equates to Charges Invoices and Payments. All these constitute your practice revenue. Because each of these three records has their own date, you can view your revenue using PPS reports in a variety of ways this does mean that running a Charges report, Invoice report and Payments report for the same month will not necessarily show the same revenue figures because the Charge date may not be the same as the Invoice date, or the Payment date. Where the term “Revenue” is used in PPS – for example on the Statistics & Summaries screen, then PPS will explain which figures it will use for revenue – in this case Charges.

Select
A term used when you choose something on the screen. Some PPS screens have a <Select> button, this normally means that you pick an option, or entry in a list, then click the <Select> button. This will “select” your chosen entry and proceed to the next screen, or return to the previous screen with your chosen entry selected.

Status
See: Client Status

Treatment Episode
All clinical notes in PPS are stored within the framework of Treatment Episodes; each time you see a client, this is a Consultation – one or more Consultations form a Treatment Episode. This allows you to see a client several times within the same Treatment Episode. Depending upon the nature of your business, it may be the case that each time you see a client this is a separate treatment episode, so the episode is “Started” and “Completed” all within the same consultation. It is possible to undertake more than one treatment episode for a client at the same time. If a client is currently in a treatment episode when you start a new consultation, you can select to start a new treatment episode from the Consultation Screen. If a client has more than one current treatment episode, then when you start a consultation, you can select which treatment episode that this consultation is for. A Treatment Episode in PPS includes a range of details that you can enter to give you a wide range of options for your reporting and statistics analysis. In addition to the Start and End dates of an episode, you can also categorise your diagnosis, treatment, outcome and discharge details, as well as entering certain information about the presenting problem such as Acute/Chronic, Time Present, etc. This is designed to assist you with your follow up consultations, as these details are displayed at the top of the Consultation screen while you are entering your consultation notes.