Quick Guide
Medication Management
Comprehensive Guide
Quick Guide
Quick Guides
Outpatient Prescriber 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 | 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. 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 “Client Search.” | 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] Service Note Reviewer Screen Client Abbreviated Notes Report | 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. Use the Service Note Reviewer screen to look at signed Service Notes PDFs 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 | How to View Previous Service Notes via the Service Note Reviewer Screen | How to See a Summary of a Client’s Services Notes Using Client 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 | Client Orders or Quick Orders. Any POCT can be added manually by your administrative team. Please ensure that a lab diagnosis is included. Can trend lab results within Flowsheets or use the Cumulative Lab Report to be able to trend data over time. | 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 “Progress Note” 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 “Vitals/Meaningful Use” 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 | |||
| Start a E&M Psych Note | Services/Notes [Client], Staff Calendar and/or Appointment for Today widget on the Provider’s Dashboard. In Service tab, change “Scheduled” to “Show.” | 90792-Prescriber Assessment E/M (OP): Used for formal psychiatric evaluation, including integrated biopsychosocial and medical assessment 99202-99205 Prescriber New E/M (OP) : Used to document E/M medication support services provided to new patients and/or > 3 years since last visit 99212-99215-Prescriber Progress E/M (OP): 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. | Service Code Definitions | Choosing Procedures | How to Complete the Psych/Medical Note | How to Add/Edit and Use Key Phrases w/Permission Only |
| 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 | How to Create Standing Orders | ||
| Order Outpatient Medications | Medication Management (Rx) (Client) | 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 | |
| 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 | ||||
| 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. | How to Add a Co-Signer to a Document | How to Co-Sign a Document | ||
| Assessments: PHQ-9 and GAD-7, AIMS | Search for PHQ-9, GAD-7, or AIMS | 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) --> “Add medications" to captured home non-prescribed medications. Use Medication Reconcilliation 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? | √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