Templates: Evaluations

Evaluations Templates are the foundation for your Kipu EMR documentation and are generally more complex than consent forms. They allow for a patient signature, as well as staff (by function), and supervising staff (reviewer). 

Creating an Evaluation

Let's review how to create a new evaluation template.

1. To create Evaluations go to Templates > Evaluations.
2. Select New Evaluation to create your evaluation form. Click the Edit icon to make changes to an existing form.
3. Give your evaluation a name and select the Enabled checkbox.
4. Click the Add button to continue onto the body of the form.
5. If your instance has the Template Preview feature enabled, you can click on the Preview checkbox to view a preview of the form as you build it. Only the name will display until you add items. This feature can be enabled by a super admin under Settings > Instance.
6. Next, configure the parameters and options that determine how the form behaves.

General Evaluation Settings

The following options are available for selection:

• Patient Process [Required]: Select which patient process (patient chart tab) this form will be accessible from. 
• Enabled: Check to enable the form, alternatively uncheck to disable it if the evaluation is no longer needed.
• Billable: When checked, this evaluation will be included in the billing audit tool report. This feature is used by organizations with an integrated billing solution like CMD or the Kipu RCM. All billable evaluations must contain the field Evaluation Start and End Time. 
• Allow tech access: If you want users with the Tech role to be able to use/access this form check this box, otherwise they are not able to access the evaluation.
• Show patient photo in header: Displays the patient picture in the top-right corner of the evaluation for identification purposes.
• Load manually: Check this box to prevent the form from being added when the Populate with Forms button is selected on the patient chart. When checked, the form can only be added using the Add Form button on the patient chart tab. 
• Only one per patient: Stops a user from adding more than one of these evaluation forms to the patient chart for the same episode of care. If a mistake was made on the form, a Super Admin must delete the form before it can be re-added.

The following options are available for selection:

• Evaluation type: Choose one of the following:
  • Standard form: Any ongoing assessment/evaluation. This is the most commonly used option.
  • Pre-admission form: Allows you to perform assessments prior to the patient's admission. This type of form does not require the patient record to have an MR Number. 
  • Insurance form: These forms will be available next to the built-in Insurance Verification button on the patient facesheet, and can be used to document additional insurance questions or concerns.
  • Important: Once signed, the date and time of the patient's signature will automatically populate the discharge date field on the Face Sheet, thereby discharging the client. 
• Evaluation content: Select one of the following:
  • Standard: Any ongoing assessment/evaluation. This is the most commonly used option.
  • Notes/Logs: Turns the evaluation into an ongoing note or log format. Must be used with field type Notes  or Glucose Log and cannot have any other items (fields). This evaluation content type does not allow for signatures (the author of the note or log entry gets recorded, along with the date/time of the entry).
  • Treatment plan: Contains built-in functionalities that allow users with the role of Therapist/Other Therapist to work on the evaluation on an ongoing basis until it has been closed. Treatment plans can be categorized by Modalities (Medical, Clinical, Holistic, etc.).
• Locked: No further edits can be made to this template.
• Portal: Check the Available box to share this evaluation to the Patient Portal for review and signature collection.
  • When you click the Available button, the Signatures Only checkbox will appear. If this box is checked off, patients will only be able to open and sign the form in the Patient Portal, they will not be able to make any other changes.

• Recurring: Allows the evaluation to be automatically populated in the patient's chart at specific intervals (for example, CIWA-Ar every 4 hours; Nursing Assessment every 24 hours, etc.).
  • Daily start time: Select the time when the first form for the day should be populated (e.g., 9 am).
  • Interval in minutes: Enter the number of minutes from 30 to 1440 to set the frequency. If your frequency is in hours, you need to convert it to minutes, e.g. 4 hours is 240 minutes, so you would need to enter 240 in the Interval in Minutes field.
    • Important: Recurring forms can only be populated with intervals less than 24 hours (1440 minutes).
  • Show as Daily Overview: Check this box to add a dated header to the patient chart tab to house these forms.
• Link evaluation: Allows previously created forms to be linked together, making the linked form into a draft. You can unlink them just as you would a normal draft.

Billing Settings

When you select the Billable checkbox, a new section will appear which allows you to configure the related billing options. Click here to learn more.

Required Signatures

You may require multiple signature levels:

• Patient (and Guarantor and/or Guardian if listed in the patient's facesheet)
• Staff who perform the evaluation 
• Supervisory staff who review the evaluation

Staff signatures are assigned by functions, which are custom to your organization. You may assign all levels of signatures, none, or simply the ones you need. To learn about assigning Functions to users, click here.

Note: If you do not select the Patient box under Required Signatures, the patient will be able to view the evaluation but not make changes or add their signature.

Force Signatures

Assign signature requirements following your organization's policies. If you require more than one staff signature or review signature, you may also select Force Signatures to require a signature of at least one staff member per selected function.

Sign in Any Order

Please note that evaluation templates with the evaluation content set to Treatment Plan require a patient, staff, and review signature to be selected in that order to work correctly and move to the status of "In Use". This behavior applies to the regular signing process (patient/guardian/guarantor, staff, review) and the "sign in any order" option.

Important: If you have the same staff function selected in both the staff signature box and the review signature box, then they will be required to sign twice, first as staff and second as the reviewer, unless you enable Review Signature Satisfied.

Form Status

Make sure that if you check staff and/or review signatures, you select at least one responsible staff function, otherwise, the evaluation will remain In Progress, and you will be unable to close it.

Review Signature Satisfied

Allows users who are selected for both Staff and Review signatures to sign once instead of twice. Click here to learn more.

Treatment Plan Signatures

Treatment Plan Evaluation Templates must have at least one patient, staff, and review signature selected to ensure the treatment plan evaluation signature requirements can be met and will move to the In Use status correctly.

Users with the Therapist role or the Edit Treatment Plans feature can add goals, objectives, interventions, and statuses to treatment plan evaluations in the edit view even after they're signed and no longer in the In Use status. Other users will only be able to see the read-only view.

Signature Behaviors

For a form that requires patient, guardian, and/or guarantor signatures but does not have a staff signature requirement:

•  If the form is signed by the patient before a guardian/guarantor is added as a contact on the facesheet, the form will have fulfilled the patient signature requirement and will display as Completed.
• The form will not recognize a guardian or guarantor added as a contact after the form has met the patient signature requirement since, at the time of signing, only a patient signature was needed. If you need to collect guardian/guarantor signatures, a new form must be added and signed to capture all the intended signatures.

For a form that requires patient, guardian/guarantor, and Staff signatures:

• The patient can sign the form and as long as the staff signature hasn't been added, the form will not move to a completed status. 
• When the guardian/guarantor is added as a contact on the patient's chart after the patient has signed but before the staff member has signed, the guardian/guarantor will be populated as a signer on the form because the form is not in a completed status. 
• Once the guardian/guarantor contacts are added and the form recognizes the need for a Guardian/Guarantor signature, it will then allow them and the Staff to sign.

Choose Locations

If your organization has a master instance, you must designate which locations can use the the form.

Evaluation Items

Evaluation items are the form’s building blocks and make up each line of the form. You can select from a variety of field types (described below) to build the form according to your specifications e.g., checkbox, text, date, points items, etc. You can also add visual formatting options. To view a preview of your template as you build it, ensure that a super admin has enabled the Template Preview feature under Settings > Instance, and that you check off the Preview box at the top of the evaluation.

1. To create an evaluation item, click Add Item and complete the following fields, as needed.

2. Evaluation items will be collapsed by default to improve loading times. Click on the arrow in the gray bar or on Expand All to view. 

   

   • Name: Describes the item. Each name in your form should be unique, otherwise you may have a hard time finding the correct items to edit or rearrange in the evaluation. The name is shown when the Form is validated by the user but is not otherwise displayed. The number that appears is unique to that item and can be used to pre-populate information into subsequent evaluations.
   • Label: The label is visible to the end user and should be a title, question to be answered, etc.
   • Label width: This metric determines the width of the label. It is measured in percentage (%) of the whole page width.
     • Note: If you select 100% and then have items like checkboxes or radio buttons you will not see them because the label is being told to take up 100% of that space.
   • Field Type: This drop-down gives you all the options available to create your evaluation. See the Field Type section below for a complete listing of available fields. 
   • Points Group: When using a points system (assigning a score to answers to a questionnaire), this field identifies all the evaluation Items that correspond to the same group of scored answers and adds the totals. This field is used with the field types points_item and points_total. You may have multiple points groups in the same evaluation.
   • CSS Style: This field governs the style of the evaluation item.
     • Percentages determine the space or size that the field type takes up
     • P, h2, h3, h4 determine the size of the font for the field type title. 
       • p = paragraph (standard text size)
       • h2 = largest title size
       • h3 = slightly smaller title size
       • h4 = smallest title size (still larger than p)
     • Normal, textarea.small, textarea.long, textarea.inline, textarea.2_lines determine the size of the text box for that field type.
     • Check_boxes_as_list turns a checkbox item (created by using the check_box and check_box_first_value_none field types) into a list
     • Tip: If the information added to CSS Style doesn't follow the guidelines above, the evaluation may not perform as desired
   • Record names: limit with |. Points_items: 'yes'=>'10', 'zero'=>'0'
     • Record names: limit with |: Add the options for field types that require options. These options must be separated by the pipe symbol (|). For example, yes|no|maybe.
     • When the Optional checkbox is selected, you can choose the text that appears next to the checkbox to collapse the text box. For example: N/A, No, Yes, None.
     • Points_items: 'yes'=>'10', 'zero'=>'0': When creating a points items questionnaire, this field is required to enter the answers, with their corresponding points/values. You must use single apostrophes (') and separate items with commas, as with the example above. For example 'yes'=>'10', 'no'=>'0', 'maybe'=>'5'.
   • Show string (e.g. false|true|false|false): Enables you to alter any checkbox field type, so that you can provide a typed response. To include a typed response, it must be entered as true. Please note:
     • This field is only applicable to checkbox field types.
     • Typed responses can be combined with checked responses.
     • This field is only applicable if you require a typed response.
     • This field must be used in conjunction with the Record Names field and must have the same number of options For example, if your checkbox options are No|Yes|If Yes, Explain you would use false|false|true in the Show String field, to allow for a typed response to If Yes, Explain.
     • You can enter placeholder text in this field, to display as a guideline, example, or directive to the user. Once the user starts typing in the field, the placeholder text will no longer appear.
     • If you select checkboxes_as_a_list and then check the checkbox with strings but leave the string blank, the field will be blank in the form rather than showing n/a text.
     • Dynamic Matrix: This field also allows you to set up a Dynamic Matrix table by entering dynamic fields separated by this symbol (=>) to ensure that the system displays the evaluation items. (e.g. {drugList}=>1|2|3|4|5|6|7|8|9|10=>1|2|3=>{datePicker}=>{diagnosisCodes}. When creating a dynamic matrix, use the following evaluation items: 
       • {drugList}: Pulls drug names from the Substance tab in Settings 
         • Example: =>{drugList}=>
       • {datePicker}: Adds a calendar to select a date.
         • Example: =>{datePicker}=>
       • {diagnosisCodes}: Selects diagnosis from ones already entered through Manage Diagnosis Codes form. 
         • Example: =>{diagnosisCodes}=>
       • Free Text: Leave a blank box for free typing (Default option).
         • Example:=>=>
       • Dropdown: List options in a drop-down list.
         • Example: =>1|2|3=>
   • Show String CSS: Determines the width of the string when using a type-in checkbox. Width is measured in percentage (%) of the whole page width.
   • Matrix Column Names: name the columns to be used in your table (matrix or matrix_optional). Please note:
     • Names should be separated by the pipe symbol (|)
     • You can also name the rows in your table, you can do so using the Record Names field, always separated by the pipe symbol (|).
   • Matrix No. Empty Records: Provides the specified number of empty rows in the table (matrix or matrix_optional).
   • Rule: Allows for gender-specific conditioning (if male, if female, if transgender). When a rule is in place, the Evaluation Item will display only when applicable.
   • Default value for text field: Allows you to pre-populate a text field with the discharge location.
   • Pre-populate with ID: Allows an item to be pre-populated with the information from another, previously completed form when an item’s numerical ID is entered into the field. To pre-populate your item with the information from another item, enter that item’s number here. In order for this function to work as intended the following items are needed:
     • The source evaluation must be completed before the destination evaluation is loaded into the patient's chart.
     • The evaluation item must be identical in both source and destination evaluations, i.e., the question must be the same, so that the pre-populated answer makes sense. For example, text field checkboxes with identical record names, etc.
   • Divider below: Adds a line (divider) after the item.
   • Image: Allows you to upload an image. It must be used in conjunction with field type image or image_with_canvas.

Additional functions in Add Item:

• Enabled: Items are enabled by default, and must be enabled to appear in the template. If an item is not enabled, it will not appear.
• Add Items, Duplicate Item, Delete Item: these functions enable you to:
  • Add multiple blank items below your first item, in order to speed up the process of adding content.
  • Duplicate that specific item, which makes duplicating elements easier.
  • Delete item.

Field Types

The following field types are available for use in evaluations. Click on the images for a better view. 

Looking for a specific field type? Use Ctrl + F (Windows) or Cmd + F (Mac) and enter your search terms.

Field Category or Purpose	Field Type	Example
Attachments and Uploads	attachments: Allows you to attach documentation (PDFs, Word documents, etc.) or pictures to your evaluation form. When using a mobile device, you may take a picture that will upload directly to the evaluation, without saving it on the device. The max file size, regardless of format, is 100 MB.
Auto-Complete	auto_complete: Allows you to create a list of commonly used answers that can be chosen from once the user starts typing.
Care Team	care_team.Alumni_Coordinator, care_team.Case_Manager, care_team.Primary_Nurse, care_team.Primary_Therapist, care_team.UR_Coordinator: Allows you to assign care team members to a patient's chart and facesheet. These options pull from the Care Team Functions section in Settings > Clients/Patients. Other care team options will appear depending on your instance's settings.
Case Management	case_management_type: Adds a radio button that allows a provider to document if a case management service was rendered directly or indirectly.
Checkboxes and Radio Buttons	check_box: Creates checkbox options, as defined in the Record Names field. Allows you to select more than one option.
	check_box_first_value_none: Creates checkboxes, where the first one, if checked, unchecks all others, or is unchecked when any of the others is checked. (For example, this option would allow you to choose None/NA and quickly complete a form.)
	radio_buttons: Displays custom radio buttons. Radio buttons allow you to select only one option. For example, a Yes or No question, a 1 through 10 pain score, a satisfaction scale, etc.
Conditional Questions	conditional_question: Allows specific evaluation fields to appear based on the patient's response to a question. Check out this article for detailed information.
Triggering a Subsequent Evaluation	create_evaluation: Adds Yes/No radio buttons that, when Yes is selected, will add a subsequent evaluation. For example, answering yes for an item such as Does the patient have difficulty walking? would load a Fall Risk Assessment into the chart. Note for Integrated Billing Clients: if a single code is added to the subsequent evaluation, and it is marked as ancillary, the subsequent evaluation will be automatically added to the billing audit tool report.
Date and Time	datestamp: Adds a calendar to the evaluation so that a date can be entered
	timestamp: Adds a calendar, with date and time options.
Dropdown Menu	drop_down_list: Creates a drop-down menu where you can select the options entered in the Record Names field.
Dynamic Matrix	Dynamic_matrix: Allows you to create a dynamic matrix table, reducing manual typing for standardized options such as dates, drop-down items, drug names, free text, and diagnosis codes.
Evaluation Date and Time	evaluation_date: Adds a calendar. Once a date is selected, it will be included in your form’s title in the tab’s index page.  Note: This field will not be available if the evaluation is set to Billable. Use either evaluation_datetime or evaluation_start_and_end_time instead. When templates with this field type are set to billable after the fact, evaluation_date will automatically be converted to evaluation_datetime.
	evaluation_datetime: Adds a calendar, with sliding time bars, to select a date and time. Once a date and time are selected, they will be included in the form’s title.
	evaluation_start_and_end_time: Adds calendars for evaluation start and end times. This field is used to track time for billable items. When this function is used in billable items, the time elapsed between an evaluation’s start and end time is imported to the billable report and added to the total billable time
Evaluation Name	evaluation_name: Adds a text field that includes whatever is entered to the form’s name.	Evaluation Name
	evaluation_name_drop_down: Creates a menu from which you can select the custom options added in the Record Names field and add them to the evaluation name.
Formatted Text	formatted_text: Use this field type to add a data field to the evaluation, which works like other data fields in Kipu. See the Consents article for a complete list.
Golden Thread	golden_thread_tag: Add this field type to any evaluation to link it to any problem, treatment plan, goal , or objective using Kipu's Golden Thread.
	progress_note: Use this field type for progress notes that will be associated with different aspects of the episode of care (Problems, Treatment Plans, Goals, etc.).
	problem_list: Add this field type in any evaluation used to assess the patient to determine and list presenting problems.
	treatment_plan_problem: This field type allows you to build complete treatment plans (including modality, problems, goals, objectives, interventions, and status) on the go using the pre-written content from the settings.
Integrated Assessments	patient.ciwa_ar: Use this field to add and see history of the CIWA-AR in the patient's chart
	patient.ciwa_ar_current: Displays the most recently entered CIWA-AR results.
	patient.ciwa_b: Use this field to add and see the history of the CIWA-B on the patient's chart.
	patient.ciwa_b_current: Displays the most recently entered CIWA-B results.
	patient.cows: Use this field to add and see the history of the COWS on the patient's chart.
	patient.cows_current: Displays the most recently entered COWS results.
	patient.vital_signs: Records the patient’s vital signs, and includes pulse, blood pressure, temperature, oxygen saturation, respiration
	patient.vital_signs_current: Displays the most recently entered vitals signs results.
	patient.orthostatic_vital_signs: Allows you to enter the patient's orthostatic vital signs in a form instead of in the MARs or in the Doctor's Orders tab, depending on which vitals (if any) your facility has set up in the EMR settings.
	patient.orthostatic_vital_signs_current: Displays the most recently entered orthostatic vital signs.
	patient.pain_scale: Allows you to record the patient's reported pain scale.
	patient.pain_scale_current: Displays the most recently entered patient pain scale.
	patient.height_weight: Allows you to enter the patient’s height and weight. In order to record the weight and height history, this function must be used in conjunction with the evaluation_datetime field. Includes BMI information.
	patient.height_weight_current: Displays the most recently entered patient height and weight.
	patient.glucose_log: Allows you to log the patient’s blood glucose reading in any evaluation.
Image Fields	image: Allows you to add images to the form.
	image_with_canvas: Adds an image with a paint option so you can draw on or mark the image.
Matrix	matrix: Allows you to create a table, with custom columns and rows.
Notes/Logs	notes: Allows you to add notes in string form (such as the Shift notes). String notes are added by the users on an ongoing basis, and display the newest on top. This field type must be used alone and requires the Evaluation Content form set as Notes/Logs.
	glucose_log: Allows you to record glucose readings on an ongoing basis You can use this field as an ongoing log. When used this way, it must be used alone, and requires the Evaluation Content set as Notes/Logs. You can insert this field in any standard evaluation.
Patient Data Fields	patient.admission_datetime: Pulls the admission date/time from the patient's facesheet, or sends information added here from the calendar to the facesheet.
	patient.allergies: Pulls the allergies entered on the facesheet, or adds the allergies added here to the facesheet.
	patient.anticipated_discharge_date: Either populates with the anticipated discharge date from the facesheet, or if added here, will add the date to the facesheet.
	patient.brought_in_medication: Displays a list of all medications logged as brought in by the patient. Typically used with discharge forms to show whether medications were kept, continued, destroyed, or held to be returned on discharge.
	patient.bed: When occupancy is used, it creates a field that auto-populates with the patient’s bed assignment.
	patient.diagnosis_code: Creates a field for diagnosis codes that will auto-complete from the ICD-10 Database as the user types. When a patient has been diagnosed already, this field will be pre-filled with the previous diagnoses. To record the diagnosis history, this function must be used in conjunction with the evaluation_datetime field.
	patient.diagnosis_code_current: Shows the codes on the patient's chart.
	patient.diets: Populates with the dietary information from the facesheet. Information added or edited using the valuation will be added to the facesheet.
	patient.discharge_datetime: Allows you to enter a discharge date and time, or, if present on the facesheet, populates the existing date and time. Once the date and time are reached, the patient will be automatically discharged, but can be found via search or on the dashboard if they have any pending items.
	patient.discharge_medication: Adds a list of orders designated by the provider as continue after discharge. Will include a button to update the medication list and a Continue on Discharge button, which, when clicked, will allow providers to view a complete list of the patient's medications and mark any unmarked medications to be continued on discharge without navigating to the Doctors Orders tab.
	patient.discharge_type: Displays a drop-down menu where the user can select a discharge type. You can report on discharge types to track outcomes. To learn more about Discharge Types, click here.
	patient.drug_of_choice: Provides a preset list of substance options. Options will appear based on items assigned to the corresponding class in the instance's settings.
	patient.electronic_devices: Allows you to enter a patient’s items and their conditions upon admission. You may customize the device conditions in Settings > Patients > Patient Property Condition.
	patient.employer: Populates the patient’s employer information from the facesheet.
	patient.ethnicity: Populates with the patient’s race and ethnicity information from the facesheet. Customize the races and ethnicities list in Settings > Patients > Race and Settings > Patients> Ethnicity.
	patient.level_of_care_clinical: Allows you to select the patient’s clinical level of care, and effective date of change. This is the level of care determined by the therapist, and may differ from the level of care authorized by the payer.
	patient.level_of_care_ur: Allows you to select the patient’s UR level of care and date of change. This is the level of care authorized by the payer.
	patient.locker: Used at organizations that safe-keep or retain patient property or valuable items. It creates a field to enter the designated locker (or other storage method identifier).
	patient.marital_status: Populates with the patient’s marital status from the facesheet. You may customize the marital status list in Settings > Patients > Marital Status.
	patient.medication_current: Creates a list of medications currently ordered and recorded in the Doctor's Orders tab.
	patient.occupation: Populates with the patient’s occupation information from the facesheet.
	patient.recurring_forms: Adds a toggle to turn recurring forms on and off.
	patient.toggle_mars_generation: Adds a toggle to turn the Medication Administration Record (MAR)/Med Log on and off.
Points Function	points_item: Allows you to assign points to answers to a questionnaire. Answers appear in a drop-down menu and each questionnaire is defined as a points group, as described above. For example, CIWA-Ar, CIWA-B, COWS, etc.
	points_total: Calculates the total points or score in the points group.
Rounds Assignment	rounds_assignment: Allows you to add patients to existing rounds.
Text Fields	string: Inserts a line for adding text.	String
	text: Inserts a text box for adding text.
Title	title: Adds hardcoded text to the form. For example, instructions for an assessment, reference information, etc.
Treatment Plan Fields	treatment_plan_column_titles: Allows you to create three titles for the three columns above the treatment items.
	treatment_plan_item: Enables you to add editable text describing the treatment plan objectives and adds a target date and status for each objective.
	treatment_plan_master_plan: Creates a live summary of all treatment plans currently loaded in a patient’s chart. This item will only function when used alone.

Editing and Deleting Evaluations and Evaluation Items