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
When a note field in the A/P section has not been marked as confidential, a
icon displays with the words "Visible to everyone."When a note field is marked as confidential (locked), a
icon displays with the words "Not visible to patient and family" and the reason it was locked.
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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