Follow-up Prescriber Encounter Workflow
Follow-up Prescriber Encounter Workflow
On follow up visits you can access your previous notes from the Visits Tab in the chart tabs while
in the Exam stage of the encounter to pull over documentation into the current visit.
1. Click the double chevron 
to the right of a past encounter.
2. Click the Re-use arrow 
next to any section of the past encounter to add the section
to the current encounter.
Note: You can click the Re-use arrow icon 
next to the Summary header to reuse the
entire summary
*Remove any copy-forwarded telehealth documentation if not indicated for the current visit and
only copy forward your own previous notes.
1. Data Reconciliation:
• Reconcile all data with a red bar as this indicates patient has updated information
2. Reason for Visit:
• Must choose one symptom or diagnosis but may also free type a CC sentence.
3.Vitals Section:
• Document vitals.
4. HPI Section:
• Tell the interval story while addressing the various symptoms/diagnosis and current status.
• Safety assessment done here if necessary.
5. Screening Questionnaires:
• Complete PHQ-9 and/or GAD-7 if appropriate.
6. ROS Section:
• Recommend Constitutional, Neurology, and Psychiatry for every follow up visit
7. Physical Exam Section:
• Use the “Mental Status Exam” selecting pertinent positives and negatives
8. Procedure Documentation (if necessary)
• Use for scales such as Mini Mental Status Exam, AIMS, MOCA, Y-BOCS.
9. Assessment & Plan Section:
• Use .psychotherapynote to add therapy section as needed
• Enter all diagnoses and orders including prescriptions, lab orders, and referral orders.
• May also use .Telehealth, .Highrisk, .InteractiveComplexity, .Suicidescreening, .Pregnancy, .SubstanceUse and .TobaccoCessation macro(s) if indicated.
10. Discussion Note:
• Use .TreatmentPlan macro. This will include medications, therapy recommendations,
labs, referrals, and follow up plan that is visible to the patient.
11. Follow-up Section:
• Schedule next visit with patient
12. Sign-Off Stage of Encounter
• Complete billing section, review, and Close encounter (or send for review)
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