Prescriber Documentation

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 DoWhat is It Called?Pro TipEHR Website Links
See Appointment Schedule, Schedule Appointment, Start Client’s ServiceStaff Calendar and/or “Appointments for Today” widget on Provider’s DashboardSave Staff Calendar as a Quick Link to easily access scheduleHow 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 DashboardThrough 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 ClientType into the “Person Search” iconWith 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 (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 ProgramsPrograms (Client)Filter “enrolled” for current programs and remove date range to see all current enrollments.How to Save Filters and/or Create Favorites
Review LabsClient 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 DiagnosesDiagnosis 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 VitalsFlow sheet (Client) Screen and choose Vitals dropdown or within psych note, click“Exam” tabUsing a flow sheet allows you to view recorded data in graph format to track trends.How to Document Vitals
Start a E&M Psych NoteServices/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/NoteWithin Note: "Diagnosis" Tab and/or Billing DiagnosisUse 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 NotesWithin Note: "MDM" TabCalMHSA 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 LabsClient 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 MedicationsMedication 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 VisitWithin Psych Note, "MDM" Tab: Activities CompletedCan 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 RightYou will get validation pop-up with direction of where an error is if you cannot sign. After care instructions are pending development.
Co-sign NotesClick on "Co-sign" Within the Assigned Documents Widget on Providers DashboardYou can also search for "batch signature" to sign multiple documents at once.
Assessments: PHQ-9 and GAD-7, AIMSSearch 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 toolsMaking a QuickLink 
Reconcile Medications Within Programs/SystemsNo SmartCare FunctionalityFor external medication: Medication Management (Rx) --> "Add medications"
Record AllergiesMedication Management (Rx) (Client) --> Allergies/ Intolerance/Failed TrialsThis will autopopulate your note if done prior. Refresh to load into your note.How to Add an Allergy, Intolerance, or Failed Trial
Discharge InstructionsDischarge Instructions [Client]How to Complete the Discharge Instructions
Medication Management

Medication Management Rx

Thing You Want to DoWhat is It Called?
Where Can You Find It?
√Pro Tip
Send Medications to a Preferred PharmacyPreferred PharmacyCan 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 AllergiesAllergies/Intolerance/Failed TrialsRecommended 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 MedicationsMedication ListOf 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 MedicationsMedication HistoryUse 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 HistoryUse the right-hand side darker blue button. The other
Order New MedicationsNew OrderUse the right-hand side darker blue button.
Add External MedicationsAdd MedicationCan add the source of the prescription, who is the prescriber
Change an Existing OrderSelect Checkbox of Existing Medication and Choose “Change Order”
Refill an Existing OrderSelect Checkbox of Existing Medication and Choose “Re-Order”Cannot do this if controlled substance and will need a new order
Patient Medication ConsentSelect 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 OrdersQueued/Verbal Orders Widget in Providers Dashboard --> RxThis will automatically connect you to the orders pending your review.
Review New/Changed MedicationsAfter 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 SubstancesOn review screen, after clicking “Ready to Sign” and “Prescribe,” you will be prompted on phone’s HID appSwipe "Approve" green button
Review Prescription StatusClick 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 MedicationMedication List; click the “X” at leftThis will then save in medication history with end date recorded and a pop-up will allow you to record the reason.
Comprehensive Guide

Quick Guides

Basic Smartcare Functionality

Logging in to SmartCare

Common SmartCare Functionalities

List Pages Functionality
Client Search
Medical Documents

Rx Navigation and Prescriptions

Getting There and General Overview
Allergies, Intolerances, Failed Trials
Ordering Medication in Rx (Outpatient)
Medication-Related Consents


Diagnosis Entry

Problem List

Privacy and Consent

Clinical Data Access Group (CDAG)

Coordinated Care Consent & Authorizations to Disclose Confidential Information

Care Coordination

My Calendar Management

How to Document a No-Show Appointment

How to Schedule Non-Client Time


Messaging in SmartCare


Other Functionality

Error Correction Processes

Service Note Errors

Supervisor Workflows

Revision Tracking