The Psychiatric Note in SmartCare is built around Evaluation and Management, or E&M billing. There are two ways to bill E&M: time-based billing and complexity-based billing. The Psychiatric Note accommodates both. Since California is using time-based billing, there are multiple fields in this note that will not be required but are still made available to you if desired.
Many parts of the note will pull information forward, either from other parts of the patient’s chart, or from the previous psychiatric note. While the note looks large at first glance, this pull-forward feature should minimize the time it takes to document while still providing you all the information necessary.
Prescribers often use a proxy to start a note, or to transcribe a note. This is available in SmartCare. Your proxy can start this note for you. Once you’re ready to finalize the note, they simply make you the author of the service note, which allows you to make any additional changes and sign the note.
1. On your Appointments for Today widget, click on the link for the service you’re documenting.
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2. This opens the service note. Complete the service details. Most service details will already be entered, as this was done when the appointment was scheduled.
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a. Enter the Face to Face time of the service. If applicable, also enter the travel and documentation time. You can also do this after writing the note narrative.
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3. Click on the Note tab. There are multiple sub-tabs within this tab. The first tab is called General.
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a. In the General section, the age of the patient will automatically select if the client is an Adult or a Child/Adolescent.
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b. In the section labeled Today’s Chief Complaint/Reason for visit, enter the basic narrative of what the patient is being seen for. If this is a follow-up visit, the previous note’s information will be pulled forward. If you check the box “Same as Last Visit,” it will pull this information into the text field. From there you can make edits as needed.
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c. If there is someone else providing information, such as a guardian, enter this information in the “Persons Present other than Consumer” section.
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d. If you need to update previously received information, sure to select “Reviewed With Changes” for that field/section. Otherwise, the note will pull the information forward and “Reviewed with No Changes” will be automatically selected.
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e. In the Allergies section, previously entered allergies will pull forward automatically. if you need to add or edit the patient’s list of allergies, click on the “Open Allergy” button. This will open the Rx module. See [reference to allergies in Rx manual]. After making edits in the Rx Module, upon returning to the note, you may need to click Refresh.
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f. Add relevant substance use information. This allows you to add a diagnosis directly, if they qualify, but this is not required.
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g. Add relevant strengths and barriers.
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4. Navigate to the Exam sub-tab.
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a. The most recent vitals will show on the screen.
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b. To add vitals, click the Open vitals flow sheet button. For more information on how to enter vitals, see [reference to vitals section]. If you’ve added vitals, you may need to click Refresh after returning to the Psychiatric Note screen.
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c. Below vitals is the Mental Status Exam. This will pull information from the previous Psychiatric note. If you make any changes to the MSE, select “Review with changes” at the bottom of the screen. For more information on how to complete the MSE, see the SmartCare Clinical Documentation User Manual.
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5. Navigate to the Medical Decision Making tab.
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a. There is a Client Orders section where you can order labs directly from the note. This works the same way as ordering labs in the standalone form. See Ordering Labs for more information.
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b. Enter in your plan for follow-up. Again, you can use the “Same as Last Visit” checkbox to pull the previous information forward.
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c. Click on Open SmartCare RX to order or adjust any medication. Any medications already prescribed will show in this section, including self-reported medications and discontinued medications. You can also view the medication history and conduct medication reconciliation as needed. Click Refresh after returning from the Rx module to the Psychiatric Note to ensure your changes are included.
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d. Enter total face-to-face time spent, if not already included. This will adjust the billing code to match your time spent. Since California uses time-based billing, you can ignore the Counseling Activities and Non Counseling Activities sections.
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6. If indicated, navigate to the AIMS tab to complete the Abnormal Involuntary Movement Scale (AIMS).
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7. Navigate to the Diagnosis tab. If the client has already received a diagnosis, it will show. Add or make edits to the diagnosis here. You can ignore the Psychosocial and Level of Functioning Score sections, as these are legacy fields from DSM-IV days. This works the same as the standalone diagnosis document. See the SmartCare Clinical Documentation User Guide for more information on how to complete the diagnosis.
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8. If you provided psychotherapy in addition to medication support services, indicate this on the Psychotherapy tab. This defaults to not include psychotherapy.
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9. The Billing Diagnosis tab will show you which diagnoses will be pulled onto the billing. You should generally ignore this tab for ongoing services. However, if you need to change the billing order, for example you want this note to focus on the secondary diagnosis, you can re-order the diagnoses to match your service without changing the overarching diagnosis form.
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10. When you are complete, click Sign.
