New Patient Therapy Encounter Workflow
New Patient Therapy 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’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:
o Initial Therapy Office Visit
o Initial Therapy Telehealth Visit
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:
• The .therapyassessment Macro will populate with the encounter plan.
• Add the patient’s diagnosis (must be appropriate and billable).
• May also use .Telehealth and .InteractiveComplexity macro(s) if indicated
• Enter referrals in this section as needed.
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
• The .therapyplan macro will populate with the encounter plan. Include the clients
agreed upon treatment goals and the next steps to achieving them.
• Add Safety plan if necessary. May use .safetyplan macro.
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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