Year End reports identified some issues Appointments kept but no documentation including super bill Encounters not “charged” without paper encounters Variation with scheduling appointments

 Encounters should be only created in EHR when using a Communication template  Refresh History to see If encounter has been created with check in – this will prevent duplicates and charting on encounter not linked to appointment and charges to wrong encounter

 For Communication encounters created in the EHR ( right click) – The Visit type must be changed to COM Type in encounter properties by right clicking the encounter in history and selecting encounter properties.

 Brief stop in for negative lab results  PPD readings  Picking up consents other paperwork

 All appointments on the schedule must be checked in, encounter created, visit type updated to update visit type to COM Type and super bill completed.

Added Office visit : 99201NC & 99211NC  Non provider / non eligible visits Additional Visit codes  EOS, SSI Booster Diagnosis codes  Various MH Group Type  Teen Council

Stop using Health Counseling Codes: Use NC for new clients or for existing clients And Visit Codes : SSI intervention or SSI Booster And Diagnosis code Health Education V65.49

 MA/OSS – scans clinic consents, releases, & referrals. Records in EPM and shreds originals.  PSC surveys – Completed with all new clients and annually for returning clients. Score is entered in EHR and form shredded.  MH documents – MH consents, signed Tx plans, referrals are scanned in EHR and shredded.  Genograms are scanned and return to MH provider to keep in own locked file.

 Documentation for Domestic Violence / Project Connect  “How to” log off EPM and EHR  “How to” for Protocol Reports  Meaningful Use Summary of Care Document for transition PHI LOG

 For the Domestic Violence / Project Connect project we have developed a process to easily document the appropriate information. You can access the survey on the Confidential Social History template for both pediatrics and adults.  We have developed a “NextGen How To Quickie Guide” for Project Connect.

 During training some staff were trained to click the X in the upper right hand corner of the screen.  To properly log off EPM and EMR, it is required that you click File – Exit.  We have created a “NextGen How To Quickie Guide” to Properly Log off NextGen

 Utilizing Protocols in NextGen will allow you to easily and properly track patients that are due to come back for follow up testing or health maintenance.  To utilize the Protocol report and create your own, we have created a “NextGen How To Quickie Guide” for Protocol Reports.

 Meaningful Use guidelines were implemented to ensure that clinics are not only purchasing qualified electronic medical record systems, but also using them meaningfully. In order to do this NextGen provides summary report that outlines compliance in all 20 measures.  Documenting smoking status (if yes you should be providing cessation information).  Documenting BMI (if elevated you should provide counseling for a healthy weight)  Documenting meds, allergies, diagnosis, why they are in the clinic, your diagnosis, tests performed and overall plan.  Following the visit we should also be offering a Summary of Care document outlining all of these items. We have created a “NextGen How To Quickie Guide” for documenting Meaningful Use

 One Meaningful Use requirement states if you transfer a patient out of your care into the care of another provider, you are able to provide a Summary of Care Document, and document that you provided this for the transfer, in the PHI Log.  I have created a Summary of Care Document that can be accessed from the Communication Template and is outlined in the “NextGen How To Quickie Guide” for Summary of Care Document. There are certain data elements required to be on this document such as medications, allergies etc. The process will allow you to document the information you need to add and then generate a letter. This would then need to be documented in the PHI Log.

 When Protected Health Information is requested by a patient or patient representative, the request needs to be logged appropriately. (!The first step is determine if this is truly a request for records)  -If a patient wants their lab results from their previous visit – this is not a true record request  -If a patient requests their lab results and depo shots from last year – THIS is a record request and should be logged as such. (!The second step is to ensure the requestor is approved to give consent – do you need the parent signature? Is the client signature sufficient? Did the new physician request? etc)  Once you have determined that you have a true record request and it needs to be logged you should follow the steps outlined in the “NextGen How To Quickie Guide” for PHI Log.

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