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

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. 

  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.
  2.                   The Data Reconciliation tab opens.
                              
     3.                      Expand the sections and review the items.
      
Intake: Data Reconciliation cont.

     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/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
                
     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 Therapy Office Visit 
  2.      Initial Therapy 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
 
      HPI Section:
      *Data remains factual about session rather than clinician interpretation of the session*
        The .therapyHPI 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          
      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. 

      Physical Exam 
  1.       Use the “Mental Status Exam” template to complete your mental status exam (selecting pertinent positives and negatives) 
                              

      Assessment & Plan Section 
  1.  The assessment is the part of the Clinician's interpretation of session, and this portion of the encounter 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 .therapyAssessment macro will populate to the note from the encounter plan.
    1.  Must document start and end times, participants, type of therapy interventions used, and progress in treatment.
    2. Using your clinical skills to assess and interpret information from the session, build your own assessment using a biopsychosocial approach
    3. Comment on the patient’s overall acute/chronic risk of harm to self/others in the initial visit.
    4.  May also use .Telehealth and InteractiveComplexity macro(s) if indicated 
    5. 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."


  1. 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.

                  
      Discussion Note 
• This portion of the encounter is accessible to the patient via the Athena Health portal in the Patient Summary section
• The .therapyplan 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
Add Safety plan if necessary. May use .safetyplan macro.
      

      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.  
            

  1.  Complete Billing Tab – Code your patient visit
    1.  In most cases, 90791 is the appropriate Initial visit code.
    2.  For all follow up visits, use time based codes. 
    3. Close the encounter or send to Supervising Provider to 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
     HPI Section 
  1. May use .therapyHPI macro or copy forward and edit the section. • In this section include the primary reason for the visit, information observed in session, and client’s report of symptoms. • Must include comment on suicidal/homicidal ideation if applicable • Assessment of screening results • Interventions used in session
      Screening Questionnaires 
  1.       Review/Complete PHQ-9 and/or GAD-7 if appropriate 

Physical Exam Section:

• Use the “Mental Status Exam” template to complete your mental status exam selecting pertinent positives and negatives. 

      Assessment & Plan Section:

      May use .therapyassessment macro or copy forward and edit the section. • Your assessment and interpretation of the symptoms and the diagnosis
• Your assessment and interpretation of the patient and their behaviors
• Start time of therapy
• End time of therapy
• Participants
• Type of therapy and/or interventions used
• Progress in treatment

May also use .Telehealth and InteractiveComplexity 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 
  .therapyHPI macro


  • [Patient] presents with [symptoms/diagnosis] for the [duration] that is [stable, worsening, improving]. information observed in sessions: client’s assessment of symptoms: assessment of screening results/testing: interventions used in session: Suicidality, homicidally, and self harm concerns: 


 .therapyAssessment Macro

      Biopsychosocial Assessment: Start time for therapy: End time for therapy: Type of therapy(add modalities):                       Participants: Progress in therapy:


  .therapyplan Macro

      [Patient] has the following goals: The next steps to achieve these goals include: Homework: A referral to           [provider or facility]has been made (or is being considered) [Patient] will follow up in [time period

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