Follow-up Therapy Encounter Workflow

Follow-up Therapy 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.

              o If it is not filled out by the patient’s history (family, social, and past medical) must be filled out manually.

2.Reason for Visit:

       • Must choose one symptom or diagnosis but may also free type a CC sentence.

       • Must use an appropriate encounter plan:

                                                                        

3. HPI Section:

         • .therapyHPI macro will populate from the encounter plan.

 4. Screening Questionnaires:

          • Complete PHQ-9 and/or GAD-7 if appropriate

          • Review C-SSRS or complete manually.

5. Physical Exam Section:

          • Use the “Mental Status Exam” selecting pertinent positives and negatives.

 6. Procedure Documentation

           • Use if necessary for scales such as Mini Mental Status Exam, AIMS, MOCA, Y-BOCS

7. Assessment & Plan Section:

             • May use the .therapyassessment or copy forward and edit the section..

             • May also use .Telehealth and .InteractiveComplexity macro(s) if indicated

 8. Discussion Note

                • May use the .therapyplan macro. Include the clients agreed upon treatment goals and the next steps to achieving them.

9. Follow-up Section:

               • Schedule next visit with patient.  

10. Sign-Off Stage of Encounter

                 • Complete billing section, review, and Close encounter (or send for review). 

                              

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