Psych Progress Note
Getting Started in Psych Progress Notes
1. Chart Detail Section: Click this button to open the Chart Detail Section and you can view items such as AIMS, VITALS, Facesheet etc.
2. Top Bar Navigation: This Top Bar is the Note Navigation Timeline. Once you Fill in the Start Time and click Start Note All of the options 1-8 will expand. Clicking any of the Options will navigate you to the page. Example: Click “4. Labs” will navigate you to the Labs section in the note.
3. Psych Progress Note Options: Use the Non-Billable Service Checkbox to write a Non-Billable Note, or Telemedicine Checkbox to start a Telemedicine note.
4. Service Date: This will default to Today’s date, clicking the calendar icon will allow you to make any adjustments to the service date.
5. Service Start Time: You can set the Start Time to the Current Time by clicking on the text below or click on the clock icon to manually set your time.
6. Service End Time: You can se the End Time to the Current Time by clicking on the text below or click on the clock icon to manually set your time and the end time is not required to start the note.
5. Start Note: Once you have filled out Service Date and Start Time, you can click Start Note.
Managing Progress Note Auto-Saves
1. Progress Note Auto-Save: This section contains all Progress Note Auto Saves (Notes & Evaluations) & Note Auto Saves (All Notes Save every 60 seconds).
2. Note: This field notates the note type (Evaluation, Progress Note, CM 3.0).
3. Patient Name: This field contains the Patient that belongs to the note.
4. Action: Click Choose Action to Edit or Delete the note.
5. Clear All: Clicking on Clear All will clear all data in the Note Auto Save Sec
6. Completed Status: The Red X alerts you to know that this note has not been completed.
Important: Deleting a note cannot be un-done
Managing Progress Note History
1. All Progress Note History: This section contains Note History for the selected patient (Psych Note, Eval, CM 3.0)
2. Progress Note Type: The default selection is My Notes but clicking the drop-down will allow you to filter by several criteria types.
3. Days Back: This field will allow you to narrow the note selection by how many days back the Service Date was for the Selected Patient.
4. Search: Clicking this button will allow you to search for a Specific Progress Note.
5. Action: Once results have been returned you can click action on any note to: Amend, Edit, Print and View.
Please Note: Edit is no longer an option 24 hours after completing a note
History Tab
1. History: The active tab will highlight in a Darker Blue color to indicate what tab you are working inside. Simply Click any of the tabs to navigate to the appropriate section.
2. Book Icon: Click on this book Icon will expand a list of all previous notes entered by any previous provider that entered in information on the active client.
3. Date: After clicking the Book Icon a list will expand, it will sort by most the most recent notes, going back 365 days.
4. Note: The note will contain all the previous information entered for the active patient relating to the field (Chief Complaint).
5. User: This would list the provider that entered in the note for the active patient.
6. Copy/Plus Icon: Clicking the + icon will copy the body of the Note into the active field (Chief Complaint).
Please Note: After you copy the field, you can still modify the text inside of the field.
1. HPI/Auto Filled: Any field with a Green Check mark next to the field name indicates that it will be automatically populated with the previous data entered on the active patient (Patients last encounter).
3. Quick Links: Clicking one of these quick links will replace the current field data. For example, clicking “Chronic” will replace “HPI Duration Text” with the selection, “Chronic”. Allowing you to quickly fill out the note information without needing to type.
Exam Tab
1. Exam: The active tab will highlight in a Darker Blue color to indicate what tab you are working inside of. Simply Clicking any of the other tabs will navigate you to the appropriate section.
2. Add Review for System: Clicking this dropdown will allow you to select which ROS you would like to begin review. Once selected, all the categories corresponding to the selected ROS will populate.
3. Save Template: Clicking Save Template will save all the ROS sections shown. Allowing you to create a template that will appear for each patient you see.
4. Clear Template: This will clear out any Template that you have saved in the past.
5. Load Previous ROS: This button will allow you to pull the ROS for the Active Patient from his/her last visit.
6. Clear ROS: Clicking this will clear at all of the selected fields, letting you build a new ROS.
7. ROS Category: After selecting a ROS (Example: Frequent Infections), all the categories will appear. To select any appropriate category, simply click on the category name. Once you click on the category, it will darken the background behind the text.
8. Free-Text: With any category selection, you can free-text any additional details you would like to notate on the category selection.
1. Save Template: Clicking Save Template will save all the MSE selections shown. Allowing you to create a template that will appear for each patient you see.
2. Clear Template: Pressing Clear Template will remove your active template that populates for each patient you see.3. Load Previous MSE: This button will pull all the previous MSE selections from the active patient’s previous encounter.
4. Clear MSES: This will remove all field selections from the MSE section.
5. Selection: Clicking the field Age Appropriate will select the value for Fund of Knowledge.
6. Free Text: All the MSE fields allow you to free-text anything that would pertain to its corresponding section.
7. Multi-select: Any field name with a “(*)” next to it, indicates that you can select multiple values. Simply hold Control on your keyboard and click each value you want to select.
Labs Tab
1. Labs: The active tab will highlight in a Darker blue color to indicate what tab you are working inside of. Simply Clicking any of the other tabs will navigate you to the appropriate section.
2. Filter: Selecting the filter field will allow you to select: Past 1 Year, Past 6 Months, Most Recent.
3. Returned: Selecting the checkbox, “Only show lab orders with resulted returned” will only show labs with results.
4. Requested By: This field will show you who ordered the lab.
5. Lab Results: You can select Acknowledge Lab or Print lab.
6. Action: Will allow you to Acknowledge the Lab and open Associated Files.
7. Add: This button, once clicked will add a the lab to the patient list.
8. Refresh Icon: The wheel above will refresh the Lab History after the Lab Order has been added.
Prescriptions Tab
1. Prescriptions: The active tab will highlight in a Darker Blue color to indicate what tab you are working inside of. Simply Clicking any of the other tabs will navigate you to the appropriate section.
2. Refresh Icon: Any new prescriptions added since the note was started will not appear until you click the refresh icon.
3. Prescriptions History: This table will list all of the patient’s active prescriptions.
4. Open Prescription Administration Sheet: Click to manage the active patient's prescriptions (Prescribe New, Refill, D/C).
5. Other Agency Medications History: This section will show medications for the client that were prescribed outside of the organization. For example: A hospital prescribed a certain medication.
6. Add Other Agency Medications: Open up this page to add other medications here.
MDM Tab
61. MDM: The active tab will highlight in a Darker Blue color to indicate what tab you are working inside of. Simply Clicking any of the other tabs will navigate you to the appropriate section.
2. Assessment: Here is where you will assess what the problem is related to and all extra comments may be entered here.
3. Book Icon: Click on this book Icon will expand a list of all previous notes entered by any previous provider that entered in information on the active client.
4. MDM History: This section will show problem list history recorded for the patient that can be entered in from the Problem List Page and viewed here.
5. Problems and Plan: See historical information here entered in from the user from the Problem List Page.
6. Refresh Icon: Any new prescriptions added since the note was started will not appear until you click the refresh icon.
7. Assessment List: Click on the Assessment List Button to open up the Problem List and here you will be able to quickly add a new problem all from this page.
8. CSPMP: This section queries the appointments for doctors every day and returns the data in Axiom.
9. Load: Previous Coordination: Click on this to load in any previous data.
10. *Make sure all sections with the (*) Are filled out before you move to the next page.
Services Tab
2. Service Site: Select the site where the encounter took place.
3. Provider: This field is not editable, just informing you of the Attending Physician.
4. Service List: Depending on the information entered in the note, Axiom will automatically select the service code. 90785 is the auto detected service for the entered information.
5. Start Time: List the Start Time for the Service Code
6. End Time: Enter the End Time for the Service Code or click Set to .Current Time to automatically populate the current time from your PC.
7. POS: Enter the Place of Service for the encounter.
8. Manual Enter Service: See Below Section.
Manually Enter Service Codes
2. Service Site: Select the site where the encounter took place.
3. Provider: This field is not editable, just informing you of the Attending Provider
4. Service List: Select the appropriate service for the encounter.
5. Duration: Type your Duration Time for how long you were with the patient in the appointment.
6. Start Time: List the Start Time for the Service Code.
7. End Time: Enter the End Time for the Service Code or click Set to Current Time to automatically populate the current time from your PC.
8. POS: Enter the Place of Service for the specific service codes.
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7. End Time: Enter the End Time for the Service Code or click Set to Current Time to automatically populate the current time from your PC.
8. POS: Enter the Place of Service for the specific service codes.
Please Note: If you select multiple service codes, please ensure that they do not have any overlapping start & end times.
CONFIDENTIAL AND PROPRIETARY INFORMATION - NOT FOR DISTRIBUTION Copyright © 2020 Health Information Management Systems, LLC Related Articles
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