Quick Guide
Medication Management
Comprehensive Guide
Quick Guide
Quick Guides
Outpatient Nurse Workflow
| Thing You Want to Do | What is It Called? | Pro Tip | |
|---|---|---|---|
| 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 autopopulate, if a client is assigned to you as the primary provider. | How to Create an Appointment from Your Calendar 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 widget’s hyperlink. Can also search all messages/alerts under Message/ Alert screen. Can attach a document by going to the completed document PDF and sending it as part of a message. Nurses can be added as a proxy to answer messages for physicians. | How to Create an Appointment from Your Calendar The Appointments For Today Widget |
| Look up Client | Person Search Icon | The Person Search icon will autofilter when you type in the first 3 letters and or medical record number. For a more extensive search, under Person Search icon, select “Client Search.” | How to Create an Appointment from Your Calendar The Appointments For Today Widget |
| Review Previous Services/Notes | Services/Notes [Client] and/or Documents [Clients] | Filter “Complete” in Services/Notes screen. Click hyperlink under “Document” to access a specific note. You can also filter by “Signed” in Documents screen. If within a note’s PDF, use forward or backward arrow to see notes. | How to Save Filters and/or Create Favorites |
| Review Previous and Current Programs | Programs (Client) | Filter by “Enrolled” for current programs. Remove 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. | 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 “Reviewed” vs. “Nurse Reviewed,” 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 |
| Review Diagnoses | Diagnosis Document [Client] and Client Clinical Problems | Of note, when clinicians enter problems in their progress notes, this information will go into Client Clinical Problems. For diagnoses entered by physicians, we recommend reviewing the Diagnosis Document. This is in development for merging together. | |
| Review/Document Vitals | Flow sheet [Client], choose “Meaningful Vitals” from dropdown and select “New” 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 “Service” tab to access note, switch from “Scheduled” to “Show.” This will autopopulate with pre-selected note template. | Common Nurse Procedure Codes based on RN role: •Nursing Evaluation (T1001) •Crisis Intervention/Mobile Crisis (H2011) •Medication Training and Support (H0034) •Medication Injection (96372) •TCM/ICC (T1017)-Targeted Case Management •Brief Contact Note (Non-billable) •Team Case Conference, Client/Family present (99366) •Team Case Conference, Client/Family absent (99367) | Choosing Procedures |
| Add to the Client Clinical Problems | 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 “Progress Note” it will have this functionality. This is different from the Diagnosis Document, which will autofill the Billing Diagnosis, but currently is under development to directly fill the Client Clinical Problems. | |
| Confirm the Primary Diagnosis to the Service | Once in the note, select "Billing Diagnosis" tab | 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 prescriber’s name; if you are proxy, enter your password to send order to prescriber to sign. | How to Order Labs |
| Order Outpatient Medications for Your Prescriber | Medication Management (Rx) [Client] --> Queue Orders / Verbal Order read-back | Can “Queue Order” if you need a prescriber to sign before sending. If you have permission to directly send to a pharmacy, then select your prescriber’s name and click “Prescribe.” 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. After care instructions are pending development. | |
| 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. | |
| Assessments | Within Client Quick Links --> Assessment/ Screening Tools to find full list of other available tools | Making a QuickLink | |
| Reconcile Outpatient Medications Within Programs/Systems | No SmartCare Functionality | For external medications: Medication Management (Rx) --> “Add medications.” | |
| Record Allergies | Medication Management (Rx) [Client] --> Allergies/ Intolerance/Failed Trials | How to Add an Allergy, Intolerance, or Failed Trial |
Medication Management
Medication Management Rx
| Thing You Want to Do | What is It Called? Where Can You Find It? | √Pro 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 “intolerance” and/or “failed trial.” |
| 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 “Change Order” | |
| Refill an Existing Order | Select Checkbox of Existing Medication and Choose “Re-Order” | Cannot do this if controlled substance and will need a new order |
| Patient Medication Consent | Select Checkbox of Medication and Choose “Patient Consent” | 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 “Prescribe” button, a review screen will appear. If you approve, then choose “prescribe” a second time. | Make sure you check the checkbox under “ready to sign.” |
| Approve Conrolled Substances | On review screen, after clicking “Ready to Sign” and “Prescribe,” you will be prompted on phone’s HID app | Swipe "Approve" green button |
| Review Prescription Status | Click on a hyperlink of a medication name --> Script History -- Check “Status” | 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 “prescriber” 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 “X” 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
Quick Guide
Smart Care Paper Consent Forms