Add Patient

In the Kipu EMR, each patient chart has three phases: Pre-Admission, Admission, and Discharged/Closed.

Pre-Admission Chart

The first step to creating a new patient chart in Kipu is to create the Pre-Admission record. This step allows the clinic to collect basic information about the patient and can be used to verify coverage prior to admission. Let’s dive in.

1. From the Patients tab, click New.
  - Note: The name of this tab can be customized, so your second tab may say “Clients” or something else depending on the nomenclature used by your organization.
2. Complete the New Patient Details:
  - Rep on Intake Call: This is the user who enters the information but can be updated if needed.
  - Referrer: Indicate if the patient was referred by selecting the referrer from the list (pulls from your Contacts page). This information can be added later if needed.
  - Required to Contact: ?
  - First, Middle, Last Name: Enter the patient's name. Only first and last are required.
  - Preferred Name: If the patient has a nickname or preferred name, you can enter that here.
  - Birth/Maiden Name: If the patient has undergone a name change, you can enter their previous name here.
  - Admission Date: Indicate the patient’s admission date (optional).
  - Discharge: This is the patient's discharge date (optional).
  - Location: Select a Location for this patient chart, typically this is where they will be treated at.
3. Click Add patient to create their chart.
4. The top section of the patient’s information tab—often called the patient facesheet— is known as the pre-admission section. This section can only be edited when the patient is in this pre-admission status. Once the patient is admitted (has an MRN assigned) you’ll no longer be able to make updates.
5. You can complete any additional patient information fields that you have, or these can be completed when admitting the patient.
6. All patients in Pre-Admission status can be viewed on the census by clicking on the Patients tab and clicking the Pre-Admission button.

Admitting the Patient

Next, let’s review the steps for completing the patient record and admitting the patient for treatment.

Locate the patient you want to admit and open their chart.
- Tip: Use the Search Patient box or navigate to Patients > Pre-Admission as described above.
Next, click Edit Patient. The patient information section contains many optional fields. Only fields marked with an asterisk (*) are required.
Program: You can assign the patient to a program using the drop-down. The Program date defaults to today’s date and time.
Patient Statuses: Use patient statuses to assign specific patient privileges or other use cases like adding curfew time or weekend pass. This functionality is completely customizable and is typically used after the patient has been admitted.
Tags: Add custom tags to the patient profile to help you organize and filter patients on the census. Depending on your settings, you may be able to create new tags directly from the patient chart.
The following section allows you to indicate the referrer and key dates.
- Referrer: Indicate a referral source or discharge-to facility.
- Admission Date [Required]: Set the date and time of the patient’s admission. This date can impact other functionality like billing and lab orders, so ensure this date is correct.
- Discharge/Transition Date: This field will be blank until the patient is ready to be discharged.
- Anticipated Discharge Date: This date is solely informational and can be used to indicate when the patient should finish their course of treatment, e.g., if the patient has a 60-day treatment plan, this date would be 60 days after their admission.
- Location: Indicate where the patient will receive treatment.
- Building: For in-patient use, indicate where the patient will be housed. Learn more about managing occupancy here.
- Bed: For in-patient use, indicate which bed is assigned to the patient.
- Location Date: This field defaults to the date and time the location was originally selected.
Next, complete the patient information section.
- Preferred Name: Add the patient’s preferred name, click here to learn more.
- OTO (One Time Only): This checkbox indicates that the patient is not welcome back for readmission after treatment.
- MR Number: Click Create MR Number to admit the patient. The patient will not be admitted until they have an assigned MRN.
- Birth Sex [Required]: You can also indicate the patient's Gender Identity from the drop-down if different from Birth Sex.
- Diagnosis: Indicate the patient’s diagnosis using the correct ICD-10 code(s). Diagnosis codes are required for verification of benefits and billing.
- SSN [Required]: Enter the patient social security number (required for billing).
- Date of Birth [Required]: Add the patient’s date of birth.
- Sobriety Date: You can enable this feature to track the patient’s sobriety.
- Date of Death: You can use this field to document the patient’s date and cause of death.
- Address [Required]: Enter the patient’s address. Adding the patient’s zip code will automatically fill in the city and state fields.
- Patient Photo/Patient ID: You can upload a picture of the patient for use in their chart or their ID.
Add the patient’s occupation information, if applicable.
Select the patient’s payment method, e.g., Insurance, Private Pay, etc., these fields are fully customizable in your settings.
Add the patient’s insurance information, if applicable. You can add multiple insurances to the patient chart, just be sure to select the appropriate Insurance Type/Priority. If your organization uses VOBGetter to verify the insurance information, be sure to use these instructions to fill out this part of the form.
- Insurance Company [Required]: Select proper Insurance from the drop-down using Payor ID when available or Payor Name. Do note that once the insurance is used in a level of care authorization or in a service authorization, you will no longer be able to edit or modify the actual name of the insurance. Free text is not supported with VOBGetter. Payor IDs in the EMR are color-coded:
  - Blue: Payor eligible for benefit verification through VOBGetter in the EMR or CRM.
  - Green: Internal Kipu ID
  - Purple: External Payer ID (from payer settings). Selecting a payor with an External Payor ID is critical for organizations integrated with CMD.
  - Red: The custom shortcode created on the Payors tab.
- Policy No. [Required]: Ensure that there are no spaces, slashes, or dashes
- Effective Date: Select from the calendar. This data can impact eligibility and coverage.
- Group Number: Ensure that there are no spaces, slashes, or dashes. If the group number is not provided, enter five zeros here.
- Subscriber Information [Required]: Relationship of Patient to Subscriber, First Name, Last Name, DOB, Gender, Address. If the subscriber is not known, or any of the required information for the subscriber is missing, select Self.
- Insurance Verification: If your organization does not use VOBGetter, or manually verifies insurance, click on the Insurance Verification button to open a new form and enter the verified benefit amounts into the fields based on the level of care.
- Delete Insurance: You can delete the insurance by clicking here. Do note, however, that if the insurance has already been used to bill data to an RCM system, you cannot delete it for data integrity reasons.
Pharmacy: If your organization uses eRx (ePrescribe), you can assign a specific pharmacy for the patient.
Contacts: Add contacts for the patient. This can be emergency contacts, family members, etc.
Allergies [Required]: Indicate any patient allergies including drug, food, or environmental. Select No Known Allergies or Add Allergy. Click here to learn more.
Food Restrictions: Optionally, you can indicate the patient’s preferred diet, e.g. vegan. Click Add Diet.
When you are done adding information, click Validate form.
This will confirm that all required fields are completed. If successful, you’ll receive a green alert.
Click Show Facesheet to review the completed facesheet. This is also where you can add Concurrent Reviews e.g., authorizations. Click here to learn more.