New Patient Therapy Encounter Workflow

New Patient Therapy Encounter Workflow


New Patient Therapy Encounter Workflow

*The Homepage will show Patient as Ready for Provider you will click on Patient and then hit GO TO SESSION*
     Intake: Data Reconciliation 

Review patient intake tabs/chart tabs. You will see an option to reconcile any data that your patient completed in Kyruus. 

Data Reconciliation steps: A RED alert bar appears on the left side of the Allergies, Medications, Problems, Vaccines, and History sections. To view information in other sections, open the document itself.
                                             
  1.  Click a chart tab — for example, Problems— and click the reconcile link at the top of the tab.
  2. The Data Reconciliation tab opens.
  3. Expand the sections and review the items.
      

     4.                      Resolve the conflict and Incoming Only item exists in both the chart and the incoming document, but the information is different
                                        a.      To keep the chart information, click the item on the left. 
                                        b.      To update the chart to reflect the information in the incoming document, click the item on the right. 
     5.                      After you complete all sections, click Update Chart at the top of the page. 
     6.                      Review the items and click Confirm.
     7.                      Athena updates the patient's chart based on your selections. 

      Intake: Manual Review with the Patient 
      When the patient has NOT fill out their Kyruus previsit, the Chart Tabs still need to be reviewed and MANUALLY completed.
      Patient Histories: 
  1. Navigate to the "History” tab on the left side of the chart 
  2. Review questions with patient and ask/indicate any additional responses
  3. Histories that must be documented for initial patient visit:
  4. Social History
    1. Absenteeism/presenteeism questions are required each visit                

    1. Fill out other social history questions at your discretion
  1. Family History
    1. Focus on past family psychiatric history
  2. Past Medical History
    1. Past Psychiatric History is located in this tab. Fill out the following required fields in this section:
  1. High Symptom Severity
  2. Previous Outpatient Psychiatric Treatment
  3. Previous Inpatient Psychiatric Treatment                                  
  4. Previous Inpatient Psychiatric Treatment
  5. Previously Diagnosed Psychiatric Disorders
  6. Previous Outpatient Psychiatric Disorders
  7. Prior ECT/Spravato/TMS treatment
  8. Prior Psychotropic Medications
    1. Include time frame, reasons for stopping
  9. History of Suicide Attempt
  10. History of Violence/Homicidal Ideation
  11. History of Trauma
  12. History of Substance Abuse
  13. Past Medical History



      Reason for Visit:
            • Must choose one symptom or diagnosis but may also free type a Chief Complaint sentence.
            • Must use an appropriate encounter plan:
                        o Initial Therapy Office Visit
                        o Initial Therapy Telehealth Visit




      3. HPI Section:
       * Data remains factual about session rather than clinician interpretation of the session*
        The .HPINew macro will populate to the note from the encounter plan. 
  1.   In this section include the primary reason for the visit, information observed in session, and client's report symptoms. 
  2.   *Must include comment on suicidal/homicidal ideation during initial visit     
  3.   Assessment of screening of screening results 
  4.   Interventions used in session         


  1. When a note field in each 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.


       Screening Questionnaires:
          
  1.  Review the results for PHQ-9, GAD-7 and C-SSRS. These screenings are sent to the patient in their Kyruus previsit at a cadence of every 14 days. If the patient completed the screenings during previsit, they will populate to the “Screening” section of the exam. 
    1. **If the patient has not completed the PHQ-9,GAD-7 and C-SSRS, or if you'd like to complete any additional screenings, manually enter the results in the Screening section of the exam by typing in the name of screening and selecting the appropriate checkbox. 
            
   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:             
  1.  The assessment is the part of the Clinician's interpretation of session, and any free text documentation in this section is not accessible to the patient
  2.  Add the patient’s diagnosis (must be appropriate and billable). This can be pulled from the problem list tab if the patient has seen a Geode Health provider.
  3. The .AssessmentNewoffice macro will populate to the note from the encounter plan.
  4. *For Telehealth appointments the .AssessmentNew macro will populate
  5. The .SafteyPlan_2 macro will populate to the note from the encounter plan
  6.  Must document start and end times, participants, type of therapy interventions used, and progress in treatment.
  7. Using your clinical skills to assess and interpret information from the session, build your own assessment using a biopsychosocial approach
  8. Comment on the patient’s overall acute/chronic risk of harm to self/others in the initial visit.
  9. Enter referrals in this section as needed


      8. Discussion Note
• This portion of the encounter is accessible to the patient via the Athena Health portal in the Patient Summary section
• The .Careplan_Therapy macro will populate to the note from the encounter plan.
• Include the clients agreed upon treatment goals and the next steps to achieving them.
• Include any actionable steps for clinician:
      • Referrals to other organization or professionals
      • Include an actionable steps for the patient:
            • Homework
            • Follow up


      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)