Prescriber Documentation

Quick Guide

Medication Management

Comprehensive Guide

Quick Guide

Quick Guides

EHR Essentials (PDF)

Prescriber Workflow Sheet 2-Sided (PDF)

Medication Management (PDF)

Outpatient Prescriber Visual Quick Guide

Outpatient MD Nurse Documentation Quick Guide

Outpatient Prescriber Workflow

Thing You Want to Do	What is It Called?	Pro Tip	EHR Website Links
See Appointment Schedule, Schedule Appointment, Start Client’s Service	Staff Calendar and/or “Appointments for Today” widget on Provider’s Dashboard	Save Staff Calendar as a Quick Link to easily access schedule	How to Create an Appointment from Your Calendar The Appointments For Today Widget
Send/Review Messages From Other Providers	Messages/Alerts or “New Alerts &Messages” widget on Provider’s Dashboard	Through the widget providers can view new/unread messages from other providers. Can also search for messages/alerts under Message/Alert screen. Can attach a document by going to a signed 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	Type into the “Person Search” icon	With Person Search icon, type the first 3 letters of last name and/or their medical record number and it will autofilter. For a more extensive search, under Person Search icon, select Client Search.	How to Use the Client Search Window How to Use the Client Search Icon to Find a Client in Your Caseload How to Use the Client Search Icon
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 Documents screen by “Signed.” Can save filters as favorites.	How to Save Filters and/or Create Favorites
Review Previous and Current Programs	Programs (Client)	Filter “enrolled” for current programs and remove date range to see all current enrollments.	How to Save Filters and/or Create Favorites
Review Labs	Client Orders or Quick Orders. Any POCT can be added manually by your administrative team. Please ensure that a lab diagnosis is included.		How to View Interfaced Lab Results How to Document Non-Interface Lab Results
Review Diagnoses	Diagnosis Document (Client)	Of note, when clinicians enter problems in their notes,this information will go into “Client Clinical Problems,”a separate list from Diagnosis Document.
Review/Document Vitals	Flow sheet (Client) Screen and choose Vitals dropdown or within psych note, click“Exam” tab	Using a flow sheet allows you to view recorded data in graph format to track trends.	How to Document Vitals
Start a E&M Psych Note	Services/Notes [Client], Staff Calendar and/ or Appointment for Today widget on Provider’s Dashboard. In Service tab, change “Scheduled” to “Show.”	Commonly Used Procedures: 90792-Assessment MD: Used for formal psychiatric evaluation, including integrated biopsychosocial and medical assessment 99202-99205-Medication Support New Client: Used to document E/M medication support services provided to new patients and/or > 3 years since last visit 99212-99215-Medication Support Existing Client: Used to document E/M medication support services provided to established patients, if visits within 3 years. 99202-99205 and 99212-99215 are the time-based codes used to document “standard” outpatient psychiatric visits. Choose based on time spent and if patient is new vs. established. These CPT codes use the same psych note template, so previous data will be saved from last use.	Choosing Procedures Outpatient MD Nurse Documentation Quick Guide (PDF) Service Code Definitions How to Write a Psychiatric Service Note for a Scheduled Service
Document Diagnoses Within a Service/Note	Within Note: "Diagnosis" Tab and/or Billing Diagnosis	Use ICD-10 code to will autofilter instead of descriptive text for better search. You will need to designate one primary diagnosis for the service and place it as the #1 spot of order.	How to Add a Diagnosis Reordering Diagnoses List Difficulties with Finding a Diagnoses How to Modify and/or Re-Order a Diagnosis How to Delete a Diagnosis Common Diagnoses Codes (PDF)
Problem List Within Notes	Within Note: "MDM" Tab	CalMHSA will be developing a different one in the future. When you enter a "Problem" in MDM, it does not save to "Client Clinical Problems," which clinicians will be using. You will need to enter at least 1 problem to complete your note.
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	Medication Management (Rx) (Client) and/or Within Psych Note, MDM tab: Medications “SmartCare Rx”	If prescribing controlled substances, download Identrust's HID mobile app and have a staff signature on file (Your Profile --> My preferences). Rx is also where you can sign any queued medication orders. Save as a quick link for easy access.	How to Place a New Medication Order How to Add Medications Prescribed Elsewhere Making a QuickLink
Calculate Time for Visit	Within Psych Note, "MDM" Tab: Activities Completed	Can enter different time than was scheduled under "Service" tab. This is the official time that will be used for billing purposes.
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.
Co-sign Notes	Click on "Co-sign" Within the Assigned Documents Widget on Providers Dashboard	You can also search for "batch signature" to sign multiple documents at once.
Assessments: PHQ-9 and GAD-7, AIMS	Search PHQ-9 and GAD-7. For AIMS Assessment, see Tab within Psychiatric Note Titled "AIMS"	Within Client Quick Links --> Assessment/Screening Tools to find full list of other available tools	Making a QuickLink
Reconcile Medications Within Programs/Systems	No SmartCare Functionality	For external medication: Medication Management (Rx) --> "Add medications"
Record Allergies	Medication Management (Rx) (Client) --> Allergies/ Intolerance/Failed Trials	This will autopopulate your note if done prior. Refresh to load into your note.	How to Add an Allergy, Intolerance, or Failed Trial
Discharge Instructions	Discharge Instructions [Client]		How to Complete the Discharge Instructions

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.