3. Complete Pre-Admission Assessment

The pre-admission assessment, also known as the initial assessment, is one of the most important centralized documents completed at the beginning stage of a patient's journey. The facility's healthcare professionals collect a patient’s information including medical history, substance use, mental health, and other relevant data in this document. The assessment helps determine if the patient is a good fit for the facility’s current treatment capabilities, or if the patient needs to be referred to another agency or location that treats the patient’s needs identified in the assessment.  

The Pre-Admission Assessment is typically completed in person or as a telehealth appointment.   

Note: This process only describes the pre-admission process for clients not using a CRM or Kipu integrated RCM products. 

Workflow Video

Workflow Steps

Let’s review the Kipu EMR’s best practice workflow for completing a pre-admission assessment form.  

1. To begin, click on the Schedules tab and then Scheduler.
2. Click on the desired appointment tile in the Scheduler.
3. Check the patient in by clicking on the Status drop-down menu and selecting Check-In.
4. For telehealth appointments, click Start Meeting.
5. Next, click Documents to add the Pre-Admission Assessment to the patient’s chart. The form will automatically open. For more information on adding appointments to the Scheduler, click here.
   
6. The Pre-Admission Assessment may display pre-populated information using the data collected during the preliminary screen. This information can be updated as the provider progresses through the Pre-admission Assessment. Click here for instructions on setting up pre-population.
   
   1. Note: Any fields previously configured to pre-populate from the Pre-Admission Assessment to other key forms such as the Biopsychosocial or the History & Physical evaluation will automatically flow into that evaluation once the form is added to the patient chart. 
7. If the form is completed during an in-person check-in, collect the patient’s signature in the system and click on Submit.
   
   
8. For telehealth visits, click on the Share icon to send the document to the Patient Portal where patient, guarantor, and/or guardian signatures can be collected.
   
9. The patient, guardians, and/or guarantors (if applicable) will receive a notification via email that a document is awaiting their signature in the Patient Portal.
10. The patient can open the Patient Portal to sign the document. Click here for the Patient Portal guide.
11. After the document has been signed, the staff member will receive an alert notifying a Portal Document has been completed, so the user can go into the patient’s chart and sign off the completed document. Click here for instructions on setting up notifications.
12. The staff member can then sign the Pre-Admission Assessment and click Submit.
13. Next, update the pre-admission status in the patient’s chart by navigating to the Information tab and clicking Edit Patient.
    
    
14. Select the relevant Pre-Admission Status.

The Patient Is Ineligible for Treatment 

If the patient is not a good fit for your facility, you can refer them to another facility or location to ensure that they receive the care and treatment that best suits their needs. A patient may be referred to another agency for a few reasons, including:  

• If the facility or healthcare professional determines that the patient's needs are beyond the scope of their practice or expertise. 
• If a patient requires specialized care or treatment not offered at the current facility.  
• If the facility does not accept the patient’s insurance. 
  
  Click here to learn about best practices to refer a patient to another facility.  

Workflow Deviations 

If the facility does not use Scheduler, add the Pre-Admission Assessment directly to the patient’s chart. 

1. To begin, click on the appropriate tab and click + Add Form.   
2. Select the Pre-Admission Assessment.
3. The document can be completed either in person or virtually (over the phone).  
4. If the patient is at the facility, complete the assessment, and click the Sign & Submit button.
5. Have the patient sign their name and then click Submit.
6. If the patient is assessed virtually, the form can be sent to the Patient Portal to collect appropriate signatures. Click here to learn more about the patient portal (go to step 5 and review the next steps).