New Patient Prescriber Encounter Workflow
New Patient Prescriber Encounter Workflow
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, Allergies, medications, and 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:
o Initial Psychiatric Office Visit
o Initial Psychiatric Telehealth Visit
3.Vitals Section:
• Document vitals.
4. HPI Section:
• .HPI macro will populate from the encounter plan.
5. Screening Questionnaires:
• Complete PHQ-9 and/or GAD-7 if appropriate
• Review C-SSRS or complete manually.
6. ROS Section:
• Must complete the Initial ROS template.
7. Physical Exam Section:
• Use the “Mental Status Exam” selecting pertinent positives and negatives.
8. Procedure Documentation
• Use if necessary for scales such as Mini Mental Status Exam, AIMS, MOCA, Y-BOCS.
9. Assessment & Plan Section:
• The .Assessment Macro will populate with the encounter plan.
• May also use .Telehealth, .Highrisk, .InteractiveComplexity, .Suicidescreening,
.Pregnancy, .SubstanceUse and .TobaccoCessation macro(s) if indicated.
• Enter all diagnoses and orders including prescriptions, lab orders, and referral orders.
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.
10. Discussion Note
• The .TreatmentPlan macro will populate with the encounter plan. 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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