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.

      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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