Quick Guide
Medication Management
Comprehensive Guide
Quick Guide
Quick Guides
Outpatient Nurse Workflow
| Thing You Want To Do | What is it Called | Pro Tip | CalMHSA Article Link | ||||
|---|---|---|---|---|---|---|---|
| See Appointment Schedule, Schedule Appointment, Start Client's Service | Staff Calendar and/or Appointment for Today widget on Provider's Dashboard | Save Staff Calendar as a Quick Link to easily access yours and other providers'/offices' calendars. "Appointment for Today" will auto populate, if a client is assigned to you as the primary provider. | How to Create an Appointment from Your Calendar - 2023 CalMHSA The Appointments For Today Widget | ||||
| Send/Review Messages | Messages/Alerts or New Messages/Alerts widget on Provider's Dashboard | Providers can view incoming new messages from other providers and respond by clicking on the widgetâs hyperlink. Can also search all messages/alerts under Message/ Alert screen. Nurses can be added as a proxy to answer messages for physicians. Can attach a document by going to the completed document PDF and sending it as part of a message. | How to Send a Message How to Send a Document in a Message Information on the Role of a Proxy | ||||
| Look up Client | Person Search Icon | The Person Search icon will auto filter when you type in the first 3 letters and or medical record number. For a more extensive search, under Person Search icon, select âClient Search.â | How to Use the Client Search Icon How to Use the Client Search Icon to Find a Client in Your Caseload How to Use the Client Search Window | ||||
| Review Previous Services/Notes | Services/Notes [Client] and/or Documents [Clients] Client Abbreviated Notes Report | Filter âCompleteâ in Services/Notes screen. Click hyperlink under âDocumentâ to access a specific note. You can also filter by âSignedâ in Documents screen. If within a noteâs PDF, use forward or backward arrow to see notes. Use the Abbreviated Notes Report to quickly review a compiled set of notes (eg "A/P" of notes) | How to Save Filters and/or Create Favorites Abbreviated Notes Report | ||||
| Review Previous and Current Programs | Programs Client | Filter by "Enrolled " for current programs. Remove the date range to see all current enrollments. | How to Save Filters and/or Create Favorites | ||||
| Review Labs | Lab Result Review screen: Complete list of client lab orders Can trend lab results within Flowsheets or use the Cumulative Lab Report to be able to trend data over time. | If outside lab vendor has appropriate interface with the EHR, the information will pull automatically for review. To mark that labs have been reviewed, select âReviewedâ vs. âNurse Reviewed,â and assign to a prescriber if needed. Of note, once reviewed, then this information will disappear from widget for all users. Nurses can send a notification to their Prescribers within the Lab Result Review screen, if a lab needs further attention. | How to View Interfaced Lab Results How to Document Non-Interface Lab Results CalMHSA Cumulative Lab Flowsheet Report | ||||
| Review, Add, & Modify Diagnosis | Diagnosis Document [Client] and Client Clinical Problems | For diagnoses entered by physicians, we recommend reviewing the Diagnosis Document. Please note, when clinicians enter problems in their progress notes, this information will go into Client Clinical Problems. | How to Add a Diagnosis How Modify and Re-Order Diagnoses | ||||
| Review, Add, & Modify Problem List | Client Clinical Problems screen and/or within the Progress Note. Please note this is shared list with non-psychiatrist roles and not used for billing but to provide transparency of which problems a patient has that are being addressed by different team members. | If your note is a âProgress Noteâ it will have this functionality. This is different from the Diagnosis Document, which will autofill the Billing Diagnosis. | How to Add a Problem to the Problem List | ||||
| Review/Document Vitals | Flow sheet [Client], choose âVitals/Meaningful Useâ from dropdown and select âNewâ if you want to input new vitals | Using a flow sheet allows you to view recorded data in graph format to track trends. | How to Document Vitals | ||||
| Choose Procedure Code/Note | Select Service/Notes [Client] and/or click from Calendar or Appointments Today if the service is assigned to you already. Under âServiceâ tab to access note, switch from âScheduledâ to âShow.â This will auto populate with pre-selected note template. Use key phrases with preset text templates to help be efficient with documentation. | Common Nurse Procedure Codes based on RN role: âąNursing Assessment (T1001) âąCrisis Intervention/Mobile Crisis (H2011) âąMedication Training and Support (H0034) âąMedication Injection (96372) âąTCM/ICC (T1017)-Targeted Case Management âąBrief Contact Note (Non-billable) âąTeam Case Conference, Client/Family present (99366) âąTeam Case Conference, Client/Family absent (99367) âąNurses Progress Note IP/PHF/CS/Res (Nonbillable) âąMedication Administration (H0033) | Choosing Procedures How to Complete the Psych/Medical Note CalMHSA 100 Shared Care Plan Report How to Add/Edit and Use Key Phrases w/Permission Only | ||||
| Confirm the Primary Diagnosis to the Service | Once in the note, select "Billing Diagnosis" tab. | You can add a diagnosis to the billing diagnosis but it will not automatically add to the Diagnosis Document. You may need to change the order of the diagnoses so that the primary/payable diagnosis for your service is in the #1 spot. | |||||
| Order Labs | Client Orders or Quick Orders. Any POCT can be added manually by your administrative team. Please ensure that a lab diagnosis is included. | When you order a lab, it will automatically be sent to the lab. To notify your prescriber, then add as co-signer as all orders are live when sent to labs. If you are only queuing the lab order, then switch the author to your prescriberâs name; if you are proxy, enter your password to send order to prescriber to sign. | How to Order Labs How to Create Standing Orders | ||||
| Order Outpatient Medications for Your Prescriber | Medication Management (Rx) [Client] --> Queue Orders / Verbal Order read-back | Can âQueue Orderâ if you need a prescriber to sign before sending. If you have permission to directly send to a pharmacy, then select your prescriberâs name and click âPrescribe.â You can checkbox the verbal order read-back to acknowledge that you did this verbally. Can add your prescriber to be co-signer, but the order will be live. | How to Place a New Medication Order How to Add Medications Prescribed Elsewhere Making a QuickLink | ||||
| Wrap Up a Visit | Sign Button on Upper Right | You will get validation pop-up with direction of where an error is if you cannot sign. | |||||
| Send a Note to Be Cosigned | Click on + button on the upper right corner of a signed document, and can assign a co-signer. | If notes are written on behalf of a prescriber, assign nurse to be a proxy within the set up role for a specific prescriber | How to Add a Co-Signer to a Document How to Co-Sign a Document | ||||
| Assessments | Within Client Quick Links --> Assessment/ Screening Tools to find full list of other available tools | If you need to document the AIMS, then search for "AIMS Assessment" and fill out the information. This will show the last completed AIMS score for comparison | Making a QuickLink How to Complete the AIMS Assessment | ||||
| Reconcile Outpatient Medications Within Programs/Systems | Can add home medications to be included with prescribed medication in Med Rx. Search for Medication Reconciliation to view and capture medication adherence. | For external medications: Medication Management (Rx) --> âAdd medications.â Use Medication Reconciliation list page to document if client is taking their home medications, last known dose date/time, and any reason for non-adherence. | How to Complete a Medication Reconciliation | ||||
| Record Allergies | Medication Management (Rx) [Client] --> Allergies/ Intolerance/Failed Trials | How to Update an Allergy, Intolerance, or Failed Trial | |||||
| Creating Discharge Information | Discharge Summary and Aftercare Summary Medical report | Fill out the Discharge Summary if you have to write any text, and use the Aftercare Summary Medical Report to generate medical specific discharge information that you wish to share to the next provider. | How to Complete the Discharge Summary How to Create the Aftercare Discharge Summary Medical Report |
Medication Management
Medication Management Rx
| Thing You Want to Do | What is It Called? Where Can You Find It? | âPro Tip |
|---|---|---|
| Send Medications to a Preferred Pharmacy | Preferred Pharmacy | Can select most common site and save for future use as a dropdown when you order a specific medication. Of note, the pharmacy will default back to preferred pharmacy even if a specific medication was previously ordered for a different pharmacy. |
| Record Allergies | Allergies/Intolerance/Failed Trials | Recommended to put allergies here because it will autopopulate in other parts of EHR. If the allergy is in a similar drug class as a medication you are trying to order, you will not be able to prescribe ̶ switch the allergy to âintoleranceâ and/or âfailed trial.â |
| Review Active Medications | Medication List | Of note, the current medication widget shows all medications including discontinued or voided. Can go to Medication List and filter for "current." Recommend saving filter as a favorite. |
| Review Past Medications | Medication History | Use the right-hand side darker blue button (rather than the lighter blue one, which is for Surescript's most recent list of medication in their system) |
| Review medication Consent | Consent History | Use the right-hand side darker blue button. The other |
| Order New Medications | New Order | Use the right-hand side darker blue button. |
| Add External Medications | Add Medication | Can add the source of the prescription, who is the prescriber |
| Change an Existing Order | Select Checkbox of Existing Medication and Choose âChange Orderâ | |
| Refill an Existing Order | Select Checkbox of Existing Medication and Choose âRe-Orderâ | Cannot do this if controlled substance and will need a new order |
| Patient Medication Consent | Select Checkbox of Medication and Choose âPatient Consentâ | This will pull up a document that both prescriber and client can sign. Can select and sign multiple consents all at once. |
| Sign Verbal or Queued Outpatient Medication Orders | Queued/Verbal Orders Widget in Providers Dashboard --> Rx | This will automatically connect you to the orders pending your review. |
| Review New/Changed Medications | After clicking âPrescribeâ button, a review screen will appear. If you approve, then choose âprescribeâ a second time. | Make sure you check the checkbox under âready to sign.â |
| Approve Conrolled Substances | On review screen, after clicking âReady to Signâ and âPrescribe,â you will be prompted on phoneâs HID app | Swipe "Approve" green button |
| Review Prescription Status | Click on a hyperlink of a medication name --> Script History -- Check âStatusâ | Prescribers can view a history of multiple clients in Start Page > Outbound Prescriptions. If nurses are set up as prescriber proxy they can also see prescription status (and refill request). Establishing nurses as âprescriberâ does not mean they can prescribe without doctor approval; medication orders will still go through the verbal or queued order approval process. |
| Discontinue Existing Medication | Medication List; click the âXâ at left | This will then save in medication history with end date recorded and a pop-up will allow you to record the reason. |
Comprehensive Guide