Cover
3/16/2016 5:54:00 AM
Raintree Systems Implementation for
Independent Living Pediatrics, Inc.
Handbook/ FAQ/ Set Up
July 2013
Training Modules to Complete
8/12/2013 7:06:00 PM
In order to complete the modules, you will receive an e-mail directly from
Raintree Systems, which will provide you with a login and a temporary
password. Your login will be your e-mail address and oftentimes the
password is “Raintree”. The website to access the modules is:
https://raintree.litmos.com
There are many online courses available but it is not necessary for everyone
to do all of the trainings. About half of the trainings were only for myself
and the billing staff to build our custom info into the system. These are
intended to be viewed before the live training and do not replace the live
training. The live training will specifically train everyone on the
documentation piece and posting charges.
When you receive your email, the only online modules you will need to go
through will be the following and in this order (we may add one or two more
but please start with these):
1.
2.
Raintree University- Navigations and Basics
Raintree Navigations
3.
4.
Raintree Interactive Manual Patient Management
Raintree Scheduler
ILI is currently looking into being able to offer free CEU’s for both the online
modules and the 4 hour live training. Stay tuned for this. If you do not
receive your email to start your modules individually, please email
Carrie. They are short in duration and can be done at your own pace, but
PLEASE finish them all BEFORE the live training. This will make your live
training experience more valuable and the transition into the program will be
much smoother! I will be able to track whether each person has finished the
online modules.
Setting up Raintree Icon onto your Computer/ other devices
Instructions for loading the Raintree Icon onto your
computer/device:
Setting up a Raintree Icon for Windows Users
Create a folder called “rtw” on your computer C:\ drive. Usually this
would be c:\rtw. To do this click on START then click on My
Computer then click on Local C Drive.
Once you are on your C: drive you will need to Right Click and then
select NEW and then FOLDER. This will allow you to create a new
folder which you should name RTW.
Now that you have your RTW folder created you will need to
download the Raintree client from
http://www.raintreeinc.com/public/rtclient/rtClient.exe
To the c:\rtw directory.
Once you have saved the rtclient.exe (you may need to unzip the
attachment) to your C:\rtw folder you will need to create a short cut
on your desk top.
You can do this by, Right Clicking the rtclient.exe icon and then
selecting the Send To option then select Desktop (create shortcut)
You should now have a Raintree shortcut on your desktop. Now you
want to Right Click on the new Raintree Icon that was created, and
select Properties. After you are in the properties you will need to
find the Target: (usually on the shortcut tab) In the Target: cell you
should see something that reads C:\rtw\rtclient.exe you will need to
delete this line and copy+paste the target below in that cell.
Your full target line should look like this:
Internal Users (ILI Office Location):
C:\RTW\rtClient.exe /C:\rtw\rtClient.exe /host:iliapp1
/config:Independent_live
External Users:
C:\RTW\rtClient.exe /C:\rtw\rtClient.exe /host:mail.iliflorida.com
/config:Independent_live
***once you have entered in the parameters you will need to click
on APPLY then CLOSE.
Note: if you work in the office and from home – you will need 2
icons
Once you have properly created your Raintree icon you will need to
double-click the shortcut to launch Raintree. Once connected you
should be able to enter your user name and password. (if you do not
have a user name and password you will need to contact your
Raintree Administrator)
For Android tablet
Setting up Raintree Virtual Access on an Android device
First you will need to contact Raintree Systems to have the user
accounts provisioned. Once you have your user accounts setup for
Raintree Virtual Access you can download and configure the app.
Open Google Play and search for the Go-Global app.
Install the Go-Global app.
Start the Go-Global app.
Tap the + button to add the connection info.
Enter host mobile.raintreeinc.com and user credentials. Click Add.
If you have been given Auto Launch info enter click on the server
and then look for it in the settings on the bottom. If not simply click
connect.
For Mac Computers
Contact ILI in order to request a unique login. When a user has received
their login info from Raintree Systems they can then use their browser to
establish a connection to the server.
Open the Safari web browser and type mobile.raintreeinc.com into the
address bar.
When the page has loaded you will click on the link to install the Mac OS
plugin.
Once plugin is finished downloading you can click on the plugin in the
download window
For IPad
Setting up Raintree Mobile Access on an iPAD
First you will need to contact Raintree Systems to have the user
accounts provisioned. Once you have your user accounts setup for
Raintree Mobile Access you can download and configure the app.
Open the Apple App Store and search for the Go-Global app.
Install the Go-Global app.
Start the Go-Global app.
Tap the + button to add the connection info.
Enter host and user credentials.
Once the connection has been setup you can tap it and it will launch
the connection to the mobile access server.
Once the connection is launched you will need to tap and hold the
top of the screen to bring up the ipad keyboard. You can pin the
keyboard bar to stay open so it is easier to bring up the keyboard. A
Bluetooth keyboard is preferred.
Cheat Sheet for Conversion Notes
8/12/2013 7:06:00 PM
COMPLETING CONVERSION NOTE
Conversion notes are used when adding a patient to Raintree that
has an evaluation or goals from another facility. By putting in a
Conversion Note you are converting the patient to your caseload and
then allow the goals to roll forward for daily notes and future
Evaluations.
Log in with Username and Password
Choose Patient Files
Hit “f” for find and type your client last name
Choose the client you are going to do Conversion Note
Choose Patient chart
Click in Visit History section
Click “add” on bottom or hit “a” or right click and hit “add”
Choose “Long Term Therapy Note”
Choose appropriate case
Choose “initial evaluation”
When screen pops up verify in Record Information that the “therapist”
and “assigned” match if they don’t click in the box that is empty and a list
will populate. Hit “f” or “find”and search for yourself.
Go to “Type” and choose “Conversion Note”
Go to “Eval” and choose your discipline
Go to “treatment plan” tab
Click in “Goals” and hit “a” or “add”
Type in Long Term goal
Go to Short Term goal and hit “+” to add an STG (put “ongoing” and hit the
disk icon to save, click “short term goal” and type in STG.
When you want to add another goal just hit the “+” and follow the steps
When done Hit F10 to save. The patient should now have active goals in the
correct case and now listed on your Pediatric Caseload.
Cheat Sheet for Building Schedule
8/12/2013 7:06:00 PM
Step by Step for Maintaining Work Schedule
Click “Scheduler” from main menu
Click the calendar icon
Choose “maintain work schedule”
If your name is not there….. you need to add yourself
Click on Name and put whatever name you want for your self
Click on Prov and put in your username, leave LOC blank and the dates
blank
Build your schedule:
Highlight box and drag from start time to end time
Choose location for visits
Choose “make available” and you will see this
You can also make any days/times unavailable
When done click “apply schedule”
This will pop up, pick your date range and double click end date to save it.
Choose your name here until is blue
Hit “Apply”
If prompted to “Abandon Changes” choose “Save”
Cheat Sheet for Discharge Note
8/12/2013 7:06:00 PM
Discharges are done when a patient is being discharged from Independent
Living. They are not done when it is only a therapist reassignment.
Completing a Discharge
In Raintree
Go to:
Patient Chart
Find Patient Name
Patient Chart
Click in visit history box
Right click to “add” or select “add” at the bottom
Select Long Term Therapy Note
Select the right case
Select Discharge Note
Input your user name/credential
Put correct location OR verify correct location patient was being seen.
Complete all the sections that are applicable with the discharge.
Please note this change….
If you were the last treating therapist you must complete the progress
towards goals in the discharge.
Select “No Visit” on the charge tab so there is no charge associated with this
note.
Charge Screen Cheat Sheet
8/12/2013 7:06:00 PM
CHARGE SCREEN CHEAT SHEET
This is where you bill for
Evaluations/Reevaluations/Screen
ings or Exit Evaluations. These are
just check boxes.
Check the box of the event
charged.
This where you bill for treatment
sessions conducted.
1= 15 minutes
2= 30 minutes
3= 45 minutes
4= 60 minutes
ROUND DOWN TO NEAREST 15
MIN INTERVALS
School System Therapists
Calculate the total number of 15
minute increments you worked
and indicate it in the appropriate
box above.
For example… 6.5 hour day = 26
units
Indicate the number sold to
client
All of these services are rounded UP
(not down) to nearest 15 min
increment except for travel.
1= 15 minutes
2= 30 minutes
3= 45 minutes
4= 60 minutes
TRAVEL…. Bill exact minutes
Helpful Hints- Hot Key Functions
8/12/2013 7:06:00 PM
F Key Functions:
F2:
F3:
F4:
F5:
F6:
F7:
F8:
Additional sessions (Press twice)
Temporarily leave
Lock, log out, password change
Calculator
Quick keys
Print/view options
System Information
F9: E-mail (can also print e-mail), escape to get out of e-mail (D delete, V
confim)
F10: Action Key “do it” key Save data
F11: Unshawdow an user. No longer wants to monitor another user.
Scheduler:
V: List of views
P: Print
L: List view of appointments; F: Appointments
+/- keys are for zooming page
Dark yellow: unavailable
Light yellow: available
Press A: to add new client
Check in and check out
Reschedule: Right click cut and then drag to new area
If you leave Raintree, rescheduler is deleted and appointments go back to
original spot
Cannot reschedule in all locations view, must be on single view
Can copy and paste appointment by right clicking and dragging from
reschedule box
To cancel appointment, right click on cancel with history, then, go to patient
files then appointment history
Block booking: Highlight appointment-click on T, then B, can do it to a year,
F10 to save
Adding Appointments to Schedulers
8/12/2013 7:06:00 PM
STEP BY STEP FOR ADDING PATIENTS TO THE SCHEDULER
Before you add clients to your schedule you need to make sure you have
built your own work schedule.
Choose Dashboard
Click on your schedule
The schedule defaults to daily view. If you would like to view your schedule
via weekly view click the magnifying glass with a plus sign.
Click on the date and time box that you want to schedule a client. The box
turns blue.
You can drag the box bigger or smaller depending on how long you want to
schedule the client.
Note: the boxes that are yellow are ones that you tagged as not available to
work where ones that are white are available to schedule a client.
You can add a patient by either hitting “a”, right click and select “add” or
choose the icon-
The appointment screen pops up.
a. Make sure provider is you
b. Choose location code
c. Put in type of appointment from choice menu
d. If the time doesn’t auto populate to the appropriate mins then correct it
for you appointment.
Start typing patient name and hit enter the patient list will populate and
double click the correct patient.
Hit F 10 to save
Blocking Booking Appointments
Click on patient put in schedule by following instructions above
Click on the wrench icon
Select “block book appointment”
Select the starting and ending date of the visits.
Select the recurrence schedule
Select “Block Book”
If you attempt to block book an appointment past an authorization
expiration date you will receive a warning.
Cheat Sheet for Completing a Service Ticket8/12/2013 7:06:00 PM
Cheat Sheet for Completing
Service Tickets in Raintree
Service Tickets are used when you are submitting a charge that does not
require a Raintree Electronic Medical Record attached for billing. You can do
a Service Ticket in one of the following:
Option 1
Schedule patient for type of appointment
Open as Long Term Therapy Note/ Daily Note
Open as Daily Note
Select Service Ticket in top right corner
Choose the appropriate charge
Put Time in and out (if appropriate)
Select Bill Review
F10 to Save or Select Save
Option 2
Select Patient File
Find patient
Select Patient Chart
Click in Visit Summary
Right click to Add or hit “A” to Add
Select “LONG TERM THERAPY NOTE”
NOTE… THE SERVICE TICKET OPTION IS GOING AWAY AS OF 8/29/12
Choose the correct case for your discipline
Make sure the correct information is across the top box
Complete just like you did in numbers Option 1 steps 5, 6 and 7
F10 to Save or Select Save
Checking in, Daily Note, Service Ticket
8/12/2013 7:06:00 PM
INSTRUCTIONS FOR:
CHECKING IN A PATIENT
COMPLETING DAILY NOTE
COMPLETING A SERVICE TICKET
Click on the patient you would like to check in.
To check in the patient either right click and choose “check in” or hit control
“i” on your keyboard or double click the patient and appointment.
Now that the patient is checked-in you can complete your note and service
ticket.
Double click on the appointment and you will be prompted to choose what
you want to do. For a daily note choose “daily note”.
On the next screen verify the date, time and therapist
You are ready to type your note. Click on “Daily Subjective” tab
Now you are able to comment on individual goals and indicate which
activities you did during each session.
By clicking on the “Goals” tab you can then click on each individual goals
and the screen will pop up where you can make comments on the long term
and/or short term goals. You will need to hit F10 or Save after you make
your comments on each goal. This will bring you out of the screen. When
you click on the Long Term Goals, if it is grey, you must select “Addressed
Goal” then it will turn white and allow you to make comments.
By clicking on the “Activity Log” tab you can choose activities that you
have done during that session and/or make comments on them. Please
note that you can add activities to the pick lists and make them your
favorites. To do so click on the “+” sign and you can choose which goals
you worked on. If you don’t see it there click on the “+” sign and add it
yourself. Remember it will now appear for everyone to be able to choose.
We will tell you how to do “favorites” at a later time.
You may make comments in the assessment box.
Go to the “Plan” Screen and make comments on the Home Exercise Plan and
put any additional comments about the session.
Click on the “Charges” tab. Here is where you indicate your billing at the
end of the visit.
Indicate how many units you treated. Do not round up… round down.
1= 15 minutes
2=30 minutes
3= 45 minutes
4=60 minutes
(See separate Service Ticket cheat sheet for additional information)
(Bill any other charges that might be pertinent to this visit. These
include any consultations, travel, etc…. See the attached Billing
Cheat Sheet for specifics on this.)
Indicate time and out. Duration will automatically calculate for you.
If there are NO Early Steps charges (Consult, ATENS, Travel or EE’s
then you are done. Choose Bill Review
If you have any charges that specifically relate to Early Steps billing such as
travel, consultations or ATENS evals you have some extra steps to change
who the payer is:
Before you hit “Bill Review” go to the “Charges Recap” Screen.
Hit “Refresh Charges”
All the charges should populate into this screen. Verify that they do.
You will need to follow these steps to make some changes:
Choose the line of the charge you are needing to change (travel, ATENS or
consultation)
You will need to pick Early Steps as the payor (it will either be “b” or “c”)
These are the choices of payers for the various Early Steps offices
Hillsborough and Polk Counties
Pinellas, Pasco and Hernando
Sarasota, Manatee
Once this change is completed you go back to the “Charges” screen
Then choose “Bill Review” on the bottom of the screen to complete.
Cheat Sheet for Evaluation,Re-Evaluation or Progress
Note
8/12/2013 7:06:00 PM
Cheat Sheet for Completing Evaluation/Re-Evaluation/Progress
Report
**Make sure that parent name and medicaid number are included under
patient demographics, so it pulls up on the report**
Things to remember:
*(s) Use a complete sentence
*(+) The section contains lists you can pick from
*If you leave something blank it will not pull anything over to the
narrative templates
To open a new document and prepare It, follow these steps:
Select “Patient files”
“Find” your patient
“Select” Patient chart
Right click in Visit History
Select “Add”
Select “Long Term Therapy Note”
Choose Correct Case for your discipline (OT, ST or PT)
Select “Evaluation” or “Re-Evaluation” or “Progress Report”
Make sure these two sections are selected correctly:
Make sure these two match
Make sure rendering location is filled in.
You are ready to complete the Evaluation/Re-Evaluation
Subjective
Parent/ Family Concerns (remember the “s” in parenthesis means
put in a complete sentence)
Behavioral Observations. The “+” sign means these are pick lists.
If you are in a box like this and you choose to just type in your
information vs using a pick list just select the
icon and you have
a free form text box to type your information in.
Areas of Development Causing Concern
This is where you indicate why they were referred as to what the
concern is of the family, agency or PCP.
Primary Communication
Not really necessary to complete unless they are nonverbal and use
a communication device.
If you do choose to put something in here then you need to indicate
what they use.
Medical History
(This is a template within a template). If you want to pull the
history that is in the system select that date. If you want to add or
update any of the medical history then you need to right click to
“add” a new history. Some information will pull from the first and
you can add to the new one. When doing a Re-Evaluation you need
to address the Medical History. Below are the subtitles with the
Medical History.
Pregnancy/Delivery and Following Birth:
Complete the information you know and leave blank the
information you don’ t know.
Health Issues: This is where allergies, medications, hearing and
vision information are located.
If appropriate, select “Patient has allergies” or “Patient takes no
medications”.
Also, if you have concerns regarding hearing or vision concerns and
they have not been assessed the recommendation is to put a
narrative in the Concerns box as a complete sentence.
Developmental History: These are the tabs under this section.
The Feeding/Speech/Language Section is where the specialized diet
is located. This section needs to be completed for all Medicaid kids.
The School/Therapy History Section is where you indicate where the
child is receiving other therapy if appropriate. This is also important
for Medicaid.
When done with the Medical History…….F10 to save and the MH
template will close out and save. You will be back in the Evaluation
template.
Objective Findings
This page looks different depending on whether or not you are OT,
PT or ST.
OT and PT share some of the same findings and test’s therefore
these two overlap. If one assesses before the other they can pull
them to the other.
In the left box labeled “objective findings” you will right click and
“add” to indicate a finding.
On the ST template you will get these choices:
On the PT template you will get these choices:
On the OT template you will get these choices:
Depending on which objective finding (areas assessed) you choose,
it takes you further into each template to report on that finding.
Make sure you go further into each area to explore and report on
that finding. You can later add additional objective findings at your
next re-evaluation. They will be listed by date you indicated the
finding. They will appear green when added at that visit and will be
yellow if from a previous visit (eval).
On the right side you can report on specific Standardized
assessment. When you right click to “add” a list populates of the
most popular assessments in that discipline. If you choose to
report on a test that is not listed, then you can report on it in the
“other assessment” box.
You also need to complete these two sections as well:
Assessment
This is where you report your clinical assessment.
This section is where you indicate general strengths and areas of
concern to be targeted during treatment.
Your clinical narrative will be in this box. It grows as you type.
This section here is completed during Re-Evaluations and Progress
Reports:
Treatment Plan
Adding Long and Short Term Goals
This is where new goals are added and older goals are reported on at
Re-Evals, Progress Reports and Discharges.
Click in the goals box until it turns yellow and right click to add. A
new screen pops up and you can add the long- term goal.
Leave the “Category” box blank. This will allow you to pull from a
bank of goals. These need to be revised to be more measureable.
You can use them but they need to be revised to be in compliance
with Medicaid guidelines. If the Goal is a new goal then indicate the
date in the box.
When adding the short term goals for the specific long term goal
click on the box for STG’s. Select the “+” sign and a new line will be
added for the goal.
Select the appropriate choice and hit the disk icon to save. Then
click on the line you just added and this will appear
Choose Status of goal
Whether goal is addressed or not…if
nothing is marked no information will
pull to narrative so put yes or no
% achieved or data toward goal if reeval
Short Term Goal
If new goal put a new start date
If goal ended put an end date
You will do this for each short term goal under the one long term
goal.
Once done with the Long Term Goal his F10 and save. The one longterm goal screen will close out.
Repeat all the steps above for adding another long-term goal and its
short term goals.
Remember… best practice is to have one long term and minimum
two short term goals for each objective finding of concern.
Treatment Plan Summary (must complete)
Treatment Diagnosis:
This diagnosis is what your clinical diagnosis for treatment should
be. For example, “feeding problem”, “expressive-receptive language
disorder”. We have provided a copy of the commonly used codes
for you to choose from.
Prognosis for Achieving Goal:
Prognosis for meeting goals stated
above.
Need to select why you chose that
prognosis.
Specifics that pull to Plan of Care:
Short Term Goals are typically 3
months and Long Term Goals are
typically 6 months. However, your
situation might be different.
Certification Period: The first date
is the date of when the last POC
ended. Please look at Red Flags to
see what dates to put in here.
For Medicaid the timeframe is 180
days and this will calculate the “to”
date.
If the treatment plan was reviewed
Activity Log
This section is where you indicate the activities you did during your
session. It is automatically avail on the Eval/Reevals/Progress
Notes. You don’t want anything to pull to your narrative so make
sure this box is unchecked. It will always default to being checked.
If it is not unchecked then the Label “Activity Log” will show up on
the narrative with nothing after it.
Therapeutic Techniques to be used in treatment sessions:
Indicate Techniques to be used in Treatment sessions
Recommendations:
Always check on of the Radial
(round) buttons AND the Home
Exercise Program.
F10 to Save and Sign off.
You can preview the entire document to check for any spelling
and/or grammar issues.
Remember if you change in the narrative version it will not save in
the template. It is best practice to change in template if it is
something you added.
Tasks and Amendments
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Tasks and Amending Charge Tickets
In the dashboard you have 2 tabs regarding task. Open tasks & Closed
tasks
Open Tasks tab there are 3 sections.
Open Tasks
List of all open task records assigned to you. You can also create a new task
from the
Open Tasks list. Press A to add in this list.
Open Sent Tasks
List of all open tasks that you have created.
Open Group Tasks
If you belong to any group, then all tasks assigned to this particular group
are listed in this list.
Closed Tasks
This is the list of tasks that were completed by the owner of the task –
person it is last assigned to and marked it completed
Final Route Specified
If a Final Route person is identified at the time of crating the task then the
complete button says sent to that person. When the assignee has
completed the work requested they will click the “sent to _______. At this
point the task will be marked completed in the back ground and appear in
the creators closed task list.
Please see the attached cheat sheet to help you with tasking and changing
charge tickets if sent to billing review with an error! Also, make sure you
are checking your task tab each day, Lee Ann (and others in the office) have
been tasking people when they leave items off their charge ticket which
delays billing and will not pull to the payroll report.
Time in and out: many of you are forgetting to put time in and time out
Make sure you are clicking “Show Charge Recap” BEFORE sending to bill
review. Then click Refresh Charges. Then submit to billing review! These
steps are very important.
Discharge Notes, please make sure you are checking “No visit” on the
charge ticket so a visit isn’t charged when doing a D/C summary.
If Lee Ann sends you something to amend, please save and sign off
again! If you need to fix something on your charge ticket:
Go to the patient menu from the open task screen.
Then go to Medical Records
Find the date of service that needs fixed. Click on the date of service.
Click Amend and Correct.
Click Modify
Then make your changes and then submit it to billing review again, save and
sign off again (f10).
If it is greyed out and the charge ticket does not allow you to make any
changes, please let Lee ann or Carla know.
Also, then click “send to Lee Ann or Complete on the task to alert Lee Ann
that the change has been made. You can also enter any comments back to
Lee Ann or anyone else in the office.
Treatment Session Log
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Timesheet- example only (via Excel now)
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ICD 9 Codes
8/12/2013 7:06:00 PM
Below is a guide of which ICD-9 Numbers that are most commonly
used for treating diagnosis for Pediatric OT, PT and ST. The
description provided is not necessarily the one listed in Raintree.
These descriptions were modified based on what was pulled from
the OT/PT/ST national association’s websites.
OT/PT
Description
781.2
Abnormality of Gait
756.1
Congenital Anomalies of Spine
799.51
Attention/Concentration Deficit
799.52
Cognitive Communication Deficits
718.4
Contracture of Joint
782.0
Disturbance of Skin Sensation (Sensory)
719.7
Gait Disturbance (Walking)
728.85
Hypertonia/Spasm of muscle
728.9
Unspecified Muscle, Ligament, Fascia Disorder NOS
(Hypotonia)
315.4
Dyspraxia Syndrome
781.3
Ataxia NOS, Muscular Incoordination
784.69
Agraphia, Other Symbolic Dysfunction
754.1
Torticollis (congenital)
315.9
Unspecified Delay in Development
799.53
Visuo-Spatial Deficit
742.8
Congenital Displacement of Brachial Plexus
767.6
Injury to brachial plexus secondary to birth trauma
753.4
Injury to Brachial Plexus
ST
Description
787.21
Dysphagia (oral phase)
787.23
Dysphagia (pharyngeal phase)
783.3
Feeding Difficulties and Mismanagement
783.42
Delayed Milestones
315.39
Developmental Articulation Disorder/ Phonological Disorder
783.42
Developmental Language Delay
315.2
Disorder of Written Expression & Other Specified Learning
Difficulties in Development
315.35
Fluency Disorder
784.4
Voice and Resonance Disorder
315.31
Expressive Language Disorder
315.32
Receptive or Mixed Expressive/Receptive Language Disorder
Dictionary/ Spell Check within Raintree
8/12/2013 7:06:00 PM
Dictionary / Spell Check in Raintree
Log into Raintree,
Right Click on the title bar (shows your name at the top)
Click on Settings
Click on Preferences
Click on the Editor Tab
Click on Dictionary Downloader
Click on the blue option to the Right – Download
Do this for both American and Medical.
Close out of this screen.
While still in Editor Tab, click on Spelling Options at the top.
Check the top box – to check spelling.
Click ok.
This will show you in red anything you type incorrectly.
If you’re a Mac user, I’ve been told you don’t have the title bar. If you can
log into Raintree on a Windows based computer and change the settings
there, it’s the best option. Otherwise we will find out how you change the
settings from Raintree.
Medical Consent Form (questions posed in Medical
History area of Raintree)
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Independent Living, Inc. - Pediatrics
Medical History
Name: ____________________________
DOB:_____________________________
Current Primary Care Physician/location: (This is not the Physician
Group Name)
______________________________________________________
______________________
Pregnancy
___ Normal ___With
Complications(describe)__________________________________________
__
Length of pregnancy: ______ weeks
Prenatal care:
___ was received ___ not received
Delivery was:
____vaginal
___c-section
___ emergency csection
Days in hospital: _____
NICU_______
Birth Weight: _______ Birth Height: _____
Addt’l Comments:
_____________________________________________________________
_________
_____________________________________________________________
_________________________
Following Birth
Were there any complications following birth: ____yes
____no
If so, what were they:
_____________________________________________________________
_______
_____________________________________________________________
_________________________
Diagnosed or suspected syndromes:
_________________________________________________________
_____________________________________________________________
_________________________
Health Issues
Please list:
_____________________________________________________________
________________
_____________________________________________________________
_____________________________________________________________
__________________________________________________
Allergies:
_____________________________________________________________
_________________
_____________________________________________________________
_____________________________________________________________
__________________________________________________
Current Medications:
_____________________________________________________________
_______
_____________________________________________________________
_____________________________________________________________
______________________Current Vitamins, Herbs, Minerals, Homeopathic:
_____________________________________________
_____________________________________________________________
_________________________
Hearing: ____ never tested, no concerns
____never tested, have
concerns
____ Have tested on: __________
Results were:
_____normal
_____abnormal
Other:
_____________________________________________________________
___________________
Vision:
____ never tested, no concerns ____never tested, have concerns
____ Have tested on: __________
Results were:
_____normal
_____abnormal
Other:
_____________________________________________________________
___________________
Medical History
Specialists
Name
Type
Reason/Details
Diagnostic Tests
Test
When
Reason/Details
When
Reason/Details
Surgeries/Procedures
Name
Other:
_____________________________________________________________
__________________
Contraindications/ Equipment
Contraindications/Precautions:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
__________________________________________________
Equipment:
_____________________________________________________________
_______________
_____________________________________________________________
_____________________________________________________________
__________________________________________________
Orthopedic
Conditions:____________________________________________________
_______________
_____________________________________________________________
_____________________________________________________________
__________________________________________________
Additional Comments:
_____________________________________________________________
______
_____________________________________________________________
_________________________
Developmental History
Motor/Sensory/Play History
Indicate approximate age they met milestone:
Rolling:
Walking:
Sitting:
Potty
Training:
Crawling:
Other:
Does your child lose balance easily:____yes
____no
Is your child ____left handed
____right handed
____not
determined yet
What is your child’s favorite toys or activities:
________________________________________________
_____________________________________________________________
______________________
Does your child:
Visually look at people and/or toys?
____ yes
____ no
Show negative response when touched or when touching other objects?
____ yes ____ no
Enjoy movement such as swinging or roughhousing? ____ yes
____
no
Play and/or participate in leisure activities daily? ____ yes
____ no
Involved in community programs? ____ yes
____ no
(describe
activities)_____________________________________________________
_________________
Feeding/Speech/Language History
Description of Feeding Problems:
__________________________________________________________
_____________________________________________________________
_________________________
Food Preferences/Dislikes;
_____________________________________________________________
___
_____________________________________________________________
_________________________
Specialized Diet: ____ yes ____no
Current Diet:
_____________________________________________________________
______________
_____________________________________________________________
_________________________
Current description of communication skills:
__________________________________________________
_____________________________________________________________
_________________________
_____________________________________________________________
_________________________
Areas of communication
difficulties:____________________________________________________
____
_____________________________________________________________
_________________________
Comments:
_____________________________________________________________
_______________
_____________________________________________________________
_________________________
D/C’d
D/C’d
bottle:
pacifier or
thumb
sucking:
Self
First Words:
feeding:
Puree:
Table foods:
School/Therapy History
Name of School: ____________________________________________
Grade: _______
Does your child have a current IEP? ______Yes
______ No
Has your child had psychological or neuropsychological testing? ______Yes
______ No
Previous or Current Therapy: (This must be fully disclosed or it is a
possibility of denial of payment/ or services by your insurance
company then you could become financially responsible)
Type
Where
Frequency
___ Previous
___
Currently
___ Previous
___Currently
___ Previous
___
Currently
Family Dynamics/Support (list family members living with patient)
Comments:
_____________________________________________________________
_______________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
______________
Other:
______________________________________________________
__________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
____________________
How to Access Miscellaneous Forms in Raintree
8/12/2013 7:06:00 P
How to Access Various Forms within Raintree
Forms currently available within Raintree for therapists to complete include:
How to access:
Patient Files
Find patient
Patient Chart
Select the tab that states “Contacts/Notes/Patient Forms”
Click in the box of “Patient Forms”
Right click to “Add” and select the form the list.
The forms will drop into the box and then it is able to be selected to be
completed.
Some of the forms have check boxes. At this moment, if there is a box to
check… just delete the box and put an “x” in front the item to be selected.
When done with the document, “save and exit”.
Then you can inform the appropriate office staff member via task or email
that the document is completed within the patient file.