Prescriber Encounter Workflow: New Patient/Follow-Up

Prescriber Encounter Workflow: New Patient/Follow-Up

Prescriber Encounter Workflow: New Patient  


Intake: Data Reconciliation 

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

  1.                 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, Meds— and click the reconcile link at the top of the tab.
    1. 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 Epion previsit, the Chart Tabs still need to be reviewed and MANUALLY completed.
      Allergies and Medications: 
  1.       Navigate to the “Allergies” and “Meds” tabs on the lefthand side of the chart 
  2. Review any information the patient has completed ahead of the visit as part of self-check-in
  3. Review with patient and ask/indicate additional responses by selecting the + sign and typing in the medication or allergy to add.
               
     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
     Histories that must be documented for initial patient visit"
  1.                 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
                                   
  1. Previous Inpatient Psychiatric Treatment
  2. Previously Diagnosed Psychiatric Disorders
  3. Previous Outpatient Psychiatric Disorders
  4. Prior ECT/Spravato/TMS treatment
  5. Prior Psychotropic Medications
    1. Include time frame, reasons for stopping
  6. History of Suicide Attempt
  7. History of Violence/Homicidal Ideation
  8. History of Trauma
  9. History of Substance Abuse
  10. Past Medical History




      Encounter Documentation 

      Reason for Visit 
       
Must choose one symptom or diagnosis AND select Encounter Plan option below:
  1.       Initial Psychiatric Office Visit 
  2.      Initial Psychiatric Telehealth Visit 
      *It is critical to efficient workflows to select one of the above encounter plans during the initial visit. The encounter plan will populate the template for the rest of your note. 
  1.       A free typed sentence is always encouraged
      Vitals 
  1.       Document vitals as needed
  2.       *Frequency of vital collection is left to your discretion based on the types of medications the patient is on, and does not need to be every visit. 

      
      
      HPI 
  1.       Review symptoms with the patient and rule certain diagnoses in or out (using HPI section)   
    1. The .hpi text macro will populate to the note for you to use as a guideline for documentation 
    2. Build the story or interval history
    3. You must include comment on suicidal ideation during initial visit
      Screening Questionnaires  
      
  1.       Review the results for PHQ-9 and GAD-7. These screenings are sent to the patient in their Epion 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 and GAD-7 within the past 14 days, manually enter the results in the Screening section of the exam by typing in the name of screening and selecting the appropriate checkbox. 
            
  1.      Review the C-SSRS screening under the “Find” tab in the patient’s chart. 
            
    1. **If the patient has not completed the C-SSRS screening, manually enter the results in the Screening section of the exam. 
  1.      Complete any additional screenings relevant to the patient. 
      ROS 
  1. Complete the Comprehensive Initial ROS template.  
  2. May create your own templates.   
                  
      Physical Exam 
  1.       Use the “Mental Status Exam” template to complete your mental status exam (selecting pertinent positives and negatives) 
                              

      Procedure Documentation (optional) 
  1.       The below scales are available in this section if needed: 
    1. Mini Mental Status Exam (MMSE)
    2. Abnormal Involuntary Movement Scale (AIMS)
    3. Montreal Cognitive Assessment (MOCA)
    4. Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
      Assessment & Plan Section 
  1.       Enter the patient's diagnosis
  2.       Recommend the .assessment Macro that includes the following sections: 
    1. Therapy
    2. Biopsychosocial Assessment
    3. *Include Rule out diagnosis
    4. Medication side effects
  3. .telehealth macro (auto populated if choosing encounter plan in Reason for visit) 
  4. .highrisk macro, .interactive complexity macro, .suicide macro, .pregnancy macro, .substance use macro, .tobacco cessation macro can be used if indicated.  
  5. Enter all orders for the patient including prescriptions, lab orders, and referral orders. 
                  
                  
      Discussion Note 
     The .treatment plan macro will populate to the note from the encounter plan. This will include medications, therapy recommendations, labs, referrals, and follow up plan.
                  
  1.       This is your PLAN for the patient.  They CAN see this on the portal.  Make it useful for them especially medication directions. 
      

      Follow-up
  1. Schedule next visit with patient, if possible. If you are unable to schedule the visit, use the Return to Office feature (from the Follow-Up section of your Exam) to select the appointment schedule length you would like for their subsequent appointment.  
  2. This ‘Return to Office’ will then provide a basis for front desk and call center staff to schedule follow-ups.  
  3. This feature will allow you to tailor the follow up appt length based on what you think is likely to happen at that next visit.  
      Sign-Off Stage of Encounter 
  1.       Complete billing section, review, and Close encounter.  If appropriated, may also send for review.  
            

      Follow-Up Patient Visit 
      
      On follow up visits you can access your previous notes from the Visits Tab in the chart tabs to pull over documentation into the current visit. 

      To reuse a section of a previous encounter: 

  1. In the Exam stage of the patient encounter, click the Visits tab. 
  2. Click the double chevron to the right of a past encounter. 
  3. Click the Re-use arrow   next to any section of the past encounter to add the section to the current encounter. 
      Note: You can click the Re-use arrow icon next to the summary header to reuse the entire summary.
      
      Follow-up visits require the same steps as the initial visit. 

*Remove any copy-forward telehealth documentation if not indicated for the current visit.

*Only Copy forward your  own previous notes.
     
     Data Reconciliation 
  1.       Reconcile all data with a red bar as this indicates patient has updated information
      Reason for Visit 
  1.       Must choose one symptom or diagnosis but may also free type a CC sentence
  2.       Choose "Telehealth with Video" When appropriate
     Vitals Section 
  1. Document vitals  
     HPI Section 
  1. Tell the interval story while addressing the various symptoms/diagnosis and current status. 
  2. Safety assessment done here if necessary 
      Screening Questionnaires 
  1.       Review/Complete PHQ-9 and/or GAD-7 if appropriate 
      ROS Section 
  1.       Recommend Constitutional, Neurology, and Psychiatry for every follow up visit. 
     Physical Exam Section 
  1. Use the “Mental Status Exam” template to complete your mental status exam (selecting pertinent items only)   
  2. Use .psychotherapynote to add therapy section is needed 
  3. May also use .Telehealth, .Highrisk, .InteractiveComplexity, .Suicide, .Pregnancy, .SubstanceUse and .TobaccoCessation macro(s) if indicated.  

      Discussion Note 
  1.       .treatment plan macro.  Update medications, therapy recommendations, labs, referrals, and follow up plan. 

      Follow-Up
  1.       Schedule next visit with patient, if possible. If you are unable to schedule the visit, use the Return to Office feature (from the Follow-Up section of your Exam) to select the appointment schedule length you would like for their subsequent appointment.  

      Sign-Off Stage 
  1.      Complete billing section, review, and Close encounter. May send for review of appropriate.  
      Patient appointment can be scheduled before you Close out your encounters. Please reference the “Schedule an Appointment from Sign-Off” workflow. 

      Documentation Visibility in the Patient Portal 
      
Macros 
      

  • Macro .HPI 

[Patient] presents with [symptoms/diagnosis] for the [duration] that is [stable, worsening, improving].  

      
      [Patient] is also dealing with [symptoms/diagnosis] for the [duration] that is [stable, worsening, improving].  

      Please include suicide/safety risk,  An assessment of psychosis or mania, and any other pertinent symptoms or diagnosis.   

      Macro .assessment 
            Psychotherapy  

Start Time of therapy: 

End Time of therapy: 

Participants in session:  

Psychotherapy modality  

- drop down to include:  

                                                                            Supportive therapy 

Cognitive therapy 

Behavioral modification therapy 

Motivational enhancement therapy 

Relapse prevention training 

            
                 Therapy progress note: 

Progress in therapy: 

Therapeutic Treatment Plan: 

            Biopsychosocial Assessment  (to include rule outs, decision making)  

 

Education, Risk & Complexity  

Medication consent: 

The patient gave informed consent for the treatment documented in this clinical note. We discussed the benefits and risks of medication, including precautions and potential side effects and/or adverse reactions.  Precautions and potential risks discussed include, but are not limited to:  

common side effects 

                          (drop down options): 

metabolic effects 

BBW for suicidality 

risk of serotonin syndrome 

cardiac effects 

seizure risk 

risk of addiction/abuse/dependence 

Teratogenic risk 

Stevens Johnson Syndrome 

risk of extrapyramidal movement symptoms and tardive dyskinesia 

      Macro .Suicidescreening 
                  Suicide Screening: 

The patient was screened for the following risk factors: prior attempt, current attempt, prior medically serious attempt, recent psychiatric hospital discharge, recent loss, diagnosis of mood/anxiety/psychotic/cognitive impairment, borderline personality disorder, substance use disorder, insomnia, family history of suicide, unemployment, hopelessness, making death arrangements. 

Patient and/or family were strongly urged to remove any weapons/firearms from patient's access. 

Patient and/or family were provided with emergency resources (911, 988 suicide & crisis lifeline, local ER information) 

Risk Mitigation:  

Risk factors: 

Protective factors: 

      

  • Macro .HighRisk 

(check boxes below with a place to add notes) 

High risk is met due to:  

- Chronic illness with severe exacerbation, progression, or side effects 

- Illness that pose a threat to life or bodily function 

- Drug therapy requiring intensive monitoring for toxicity 


      Macro .InteractiveComplexity 
      (drop down with a place to add notes) 

Interactive Complexity is met due to:  

-Maladaptive communication 

-Caregiver emotions/behavior that interfere with implementation of the treatment plan 

-Evidence/disclosure of a sentinel event and mandated report to a third party with initiation of discussion of the sentinel event and/or report with patient and other visit participants 

-Use of play equipment, other physical devices, interpreter or translator to communicate with the patient 

      
      Macro .Pregnancy 
       Medication risks related to pregnancy and teratogenic side effects were discussed.  Especially related to taken medications listed in this note.  Patient understands the risks, benefits, side effects and does believe that the benefits of treating her condition outweigh the risks to the baby.  Patient consented to medication trials during her first trimester. 

Macro .SubstanceAbuse 
      Patient was educated about the negative effects of illicit substances and/or non-prescribed controlled medications and/or alcohol on their mental and medical conditions, the potential interactions with the medications they are being prescribed. They were strongly urged to stop using the following substances: 

_____ (free text box to list substances) 

They were made aware of the potential risk of dismissal from our clinic if they failed to stop use. 

  • Macro .TobaccoCessation 

Patient was screened for tobacco use. They were educated about secondhand smoke exposure, smoke-free environments, assessed for cessation interest and past quit attempts.  Patient was strongly urged to stop tobacco use and offered to resources to connect patient and families to appropriate cessation. They were also offered pharmacologic options to help in stopping tobacco use. 

 

  • Macro .psychotherapynote 

Psychotherapy  

Start Time Therapy: 

End Time Therapy: 

Participants:  

Psychotherapy modality  

- drop down includes:  

Supportive therapy 

Cognitive therapy 

Behavioral modification therapy 

Motivational enhancement therapy 

Relapse prevention training 

 

Therapy progress note: 

Progress in therapy: 

 

  • Macro .TreatmentPlan 

Treatment Plan 

1. (Medication changes)  

2. (Medication changes) 

3. (Lab tests ordered) 

4. (Therapy) 

5. (Referrals) 

6. (See PCP for)  

7. (Intended follow up) 





    • Related Articles

    • 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 ...

    • Therapy (Non-Prescriber) Encounter Workflow: New Patient/Follow-Up

      Therapy (Non-Prescriber) Encounter Workflow: New Patient Intake: Data Reconciliation Review patient intake tabs. You will see an option to reconcile any data that your patient completed in Epion. Data Reconciliation steps: A RED alert bar appears on ...

    • Follow-up Prescriber Encounter Workflow

      Follow-up Prescriber Encounter Workflow On follow up visits you can access your previous notes from the Visits Tab in the chart tabs while in the Exam stage of the encounter to pull over documentation into the current visit. 1. Click the double ...

    • 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 ...

    • Follow-up Therapy Encounter Workflow

      Follow-up Therapy Encounter Workflow On follow up visits you can access your previous notes from the Visits Tab in the chart tabs while in the Exam stage of the encounter to pull over documentation into the current visit. 1. Click the double chevron ...