Psychiatric Evaluation
Getting Started in Psychiatric Evaluation
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 options 1-7 will expand. Clicking any of the Options will navigate you to the page. Example: Click “5. Prescription” will navigate you to the Prescription section in the note.
3. Psych Evaluation 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. Start Time: You can enter the Start Time manually by selecting the field, or you can click Set to Current Time (Located Underneath Field) and it will pull the current time from your computer.
6. End Time: This field is not required to start the note.
7. Start Note: Once you have filled out the 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 and will appear at the top of this list).
2. Note Type: This field notates the note type (Evaluation, Progress Note, PCP 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.
Important: Deleting a note cannot be undone
Managing Progress Note History
1. All Progress Note History: This section contains Note History for the selected patient (Psych Note, Eval, PCP 3.0, CM3, etc.)
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 Note.
5. Compare: You can select up to 4 notes of the same type to compare against each other for more information on a patient.
6. 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 and saving as complete
History Tab
1. History: The active tab will highlight in a Darker Blue color to indicate what tab you are working in. Simply Click any of the other tabs to navigate you to the appropriate section.
2. Book Icon: Click on this book Icon to 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 the most recent notes, going back 365 days.
4. Note: The note will contain all of the previous information entered for the active patient relating to the field (Chief Complaint).
5. User: This would list the provider entered in the active patient's note.
6. 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.
2. Clear HPI: Click this button to clear out the HPI section, giving you all empty fields to enter new data.
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 in. Simply Clicking any of the other tabs will navigate you to the appropriate section.
2. Add Review for System: Clicking this drop-down will allow you to select which ROS you would like to begin a 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 all of the selected fields, letting you build a new ROS.
7. ROS Category: After selecting a ROS (Example: Skin), 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.
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. Fund of Knowledge: Clicking the field Age Appropriate will select the value for Fund of Knowledge.
6. Free Text: All of 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 in. 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 lab results: 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: This shows the status of the labs, whether returned yet or not returned.
6. Action: You can select Acknowledge Lab or Print lab.
6. Action: You can select Acknowledge Lab or Print lab.
Prescriptions Tab
1. Prescriptions: The active tab will highlight in a Darker Blue color to indicate what tab you are working in. Simply Click any of the other tabs to 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. Prescription History: This table will list all of the patient’s active prescriptions.
4. Open Prescription Administration Sheet Page: Click to open the page and manage the active patient's prescriptions (Prescribe New, Refill, D/C).
Services Tab
1. Services: The active tab will be highlighted in a Darker Blue color to indicate what tab you are working inside. Simply Clicking any of the other tabs will navigate you to the appropriate section.
2. Service Site: Select the site where the encounter took place.
3. Physician: This field is not editable, just informing you of the Attending Physician
4. Service List: Select the appropriate service for the encounter.
5. Services Included: 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 specific service codes.
Please Note: If you select multiple service codes, please ensure that they do not have any overlapping start & end times.
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