New Patient Therapy Encounter Workflow

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.
  1. When a note field in the A/P section has not been marked as confidential, a  icon displays with the words "Visible to everyone."

  2. 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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