1. Evaluation and Management Note The E/M note should be launched when the user attempts to reconcile a planned event with a service code of 309 E/M Service (unspecified) or enter a 309 service using unplanned event entry. The program should store the planned event key for removal at the completion of the note; the PE should be written to the ISN PE record at that time. The system should determine whether the consumer in question is a “new patient” or “established patient” based on a search of events in the system. Any consumer with an event in the system within three years of the date of service where mw:IsPrescriber(E.STAFF) = true should be considered an established patient; otherwise they should be considered a new patient. Note: we need to confirm this, but I think this should be limited to events where ISN.FC.CPT is data-present; non-billable services shouldn’t count. On the other hand, we don’t want to skip a service being “held” for submission but that might eventually be submitted. I’m not sure if this would ever happen, however.

2. Standard MHCD form header w/ consumer info Evaluation and Management Guidance from CMS: A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC. 1000 Chief complaint CC. HPI. ROS. PFSH. SaveCancelFinish Last Saved - 4:04 pm Save [Text required to finish section.] HistoryExamAssessment Plan of Care Counseling Coordination Psychotherapy

3. Standard MHCD form header w/ consumer info HistoryExamAssessment Plan of Care Evaluation and Management CC. HPI. ROS. PFSH. SaveCancelFinish Last Saved - 4:04 pm Save Acute/New Condition Chronic Condition History of Present Illness Location Severity Timing [Brief/Extended] Quality Duration Context Modifying Factors Associated Signs/Sx Add New Condition Brief description of Condition CounselingCoordinationPsychotherapy

4. Standard MHCD form header w/ consumer info HistoryExamAssessment Plan of Care Evaluation and Management CC. HPI. ROS. PFSH. SaveCancelFinish Last Saved - 4:04 pm Save Chronic Condition Acute/New Condition Chronic Condition History of Present Illness [Brief/Extended] [Brief Description] entered on MM/DD/YYYY Location: text (show line only if data-present) Severity: text (show line only if data-present) Timing: text (show line only if data-present) Quality: text (show line only if data-present) Duration: text (show line only if data-present) Context: text (show line only if data-present) Modifying Factors: text (show line only if data-present) Associated Signs and Symptoms: text (show line only if data-present) Status of Condition [Show all conditions in scrolling box] Status update entered on MM/DD/YYYY Update text CounselingCoordinationPsychotherapy

5. Standard MHCD form header w/ consumer info Evaluation and Management Review of Systems CC. HPI. ROS. PFSH. SaveCancelFinish Last Saved - 4:04 pm Save HistoryExamAssessment Plan of Care Constitutional Systems Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskelatal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Not Reviewed [Findings from Prior Visit] No Change [Problem Pertinent/Extended/Complete] CounselingCoordinationPsychotherapy

6. Standard MHCD form header w/ consumer info HistoryExamAssessment Plan of Care Evaluation and Management CC. HPI. ROS. PFSH. SaveCancelFinish Last Saved - 4:04 pm Save Past History Family Hx Past Hx Past, Family, and/or Social History [Pertinent/Complete] Entered on MM/DD/YYYY Narrative past history text entered on prior date History update entered on MM/DD/YYYY Update text SocialHx Guidance from CMS: Past history includes experiences with illnesses, operations, injuries, and treatments Interval history covers information since the last visit. History Reviewed and Confirmed Updates/Interval History CounselingCoordinationPsychotherapy

7. Standard MHCD form header w/ consumer info HistoryExamAssessment Plan of Care Evaluation and Management CC. HPI. ROS. PFSH. SaveCancelFinish Last Saved - 4:04 pm Save Family History Family Hx Past Hx Past, Family, and/or Social History [Pertinent/Complete] Entered on MM/DD/YYYY Narrative family history text entered on prior date History update entered on MM/DD/YYYY Update text SocialHx Guidance from CMS: Family history includes a review of medical events, diseases, and hereditary conditions that may place the consumer at risk. Interval history covers information since the last visit. History Reviewed and Confirmed Updates/Interval History CounselingCoordinationPsychotherapy

8. Standard MHCD form header w/ consumer info HistoryExamAssessment Plan of Care Evaluation and Management CC. HPI. ROS. PFSH. SaveCancelFinish Last Saved - 4:04 pm Save Social History Family Hx Past Hx Past, Family, and/or Social History [Pertinent/Complete] Entered on MM/DD/YYYY Narrative social history text entered on prior date History update entered on MM/DD/YYYY Update text Social Hx Guidance from CMS: Social history includes an age appropriate review of past and current activities. Interval history covers information since the last visit. History Reviewed and Confirmed Updates/Interval History CounselingCoordinationPsychotherapy

9. Standard MHCD form header w/ consumer info Evaluation and Management Constitutional Musc Const Psych SaveCancel eCET Vitals Finish Last Saved - 4:04 pm Save HistoryExamAssessment Plan of Care Sitting Blood Pressure Standing Blood Pressure Supine Blood Pressure Pulse Rate Respiration Temperature Height Weight Body Mass Index General Appearance [Results from Nurse Checkin] [Problem Focused/Expanded Problem Focused/Detailed/Comprehensive] NormalAbnormal Vitals Not Assessed CounselingCoordinationPsychotherapy

10. Standard MHCD form header w/ consumer info Evaluation and Management Musculoskeletal Musc Const Psych SaveCancel eCET AIMS Finish Last Saved - 4:04 pm Save HistoryExamAssessment Plan of Care Muscle Strength and Tone Gait and Station [Problem Focused/Expanded Problem Focused/Detailed/Comprehensive] NormalAbnormal Not Assessed [Result from AIMS] CounselingCoordinationPsychotherapy [AIMS Due/Overdue from Task List]

11. Standard MHCD form header w/ consumer info Evaluation and Management Psychiatric Musc Const Psych SaveCancelFinish Last Saved - 4:04 pm Save HistoryExamAssessment Plan of Care Speech Thought Process Associations Abnormal/Psychotic Thoughts Judgment and Insight Orientation Recent and Remote Memory Attention and Concentration Language Fund of Knowledge Mood and Affect [Problem Focused/Expanded Problem Focused/Detailed/Comprehensive] NormalAbnormal Not Assessed CounselingCoordinationPsychotherapy

12. Standard MHCD form header w/ consumer info Evaluation and Management Guidance from AMA: Counseling is a discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risks and benefits of management (treatment) options Instructions for management (treatment) and/or follow- up Importance of compliance with chosen management (treatment) options Risk factor reduction Patient and family education MHCD Guidelines: Counseling should be documented with all new medications, at minimum. Counseling SaveCancelFinish Last Saved - 4:04 pm Save HistoryExam AssessmentPlan of Care CounselingCoordinationPsychotherapy Minutes spent during session on Counseling

13. Standard MHCD form header w/ consumer info Evaluation and Management Coordination of Care SaveCancelFinish Last Saved - 4:04 pm Save HistoryExam AssessmentPlan of Care CounselingCoordinationPsychotherapy Minutes spent during session on Coordination Description of care coordination, including with whom care was coordinated Coordination with PCP? No Yes MHCD Guidelines: Coordination with PCP should be documented at least annually.

14. Standard MHCD form header w/ consumer info Evaluation and Management Guidance from AMA: Psychotherapy is the treatment of mental illness and behavioral disturbances in which the physician or other qualified health professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development. [It includes] ongoing assessment and adjustment of psychotherapeutic interventions and may include the involvement of family member(s) or others in the treatment process. Do not report psychotherapy of less than 16 minutes duration. [Psychotherapy] must be significant and separately identifiable [from the E/M service]. Psychotherapy Psych Int Compl SaveCancelFinish Last Saved - 4:04 pm Save HistoryExamAssessment Plan of Care Counseling Coordination Psychotherapy Minutes spent during session on Psychotherapy 00

15. Standard MHCD form header w/ consumer info Evaluation and Management Guidance from AMA: Psychiatric procedures may be reported “with interactive complexity” when at least one of the following is present: 1.The need to manage maladaptive communication (related to, e.g. high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care. 2.Caregiver emotions or behavior that interferes with the caregiver's understanding and ability to assist in the implementation of the treatment plan. 3.Evidence or disclosure of a sentinel event and mandated report to third party with initiation of discussion of the sentinel event and/or report with patient and other visit participants. 4.Use of play equipment, or translator to overcome barriers to interaction between the physician and a patient who: Is not fluent in the same language as the physician, or Has not developed, or has lost, either expressive or receptive language skills. Interactive Complexity Psych Int Compl SaveCancelFinish Last Saved - 4:04 pm Save HistoryExamAssessment Plan of Care Counseling Coordination Psychotherapy Justification of complexity Interactive complexity present? No Yes

16. Data Show if not new Standard MHCD form header w/ consumer info Evaluation and Management Guidance from CMS: For a presenting problem with an established diagnosis, the record should reflect whether the problem is: - Improved, well controlled, resolving, or resolved; or - Inadequately controlled, worsening, or failing to change as expected. MHCD Guidelines: Select New Px this this is the first time you have seen this diagnosis with this consumer; the diagnosis may have been previously treated by another prescriber. Select Add’l Workup Planned if you have additional diagnostic procedures planned or ordered to make a good differential diagnosis, e.g. psych testing or lab work to rule out physical etiology. Do not select this just for referring the consumer to another physician for future care. Assessment SaveCancelFinish Last Saved - 4:04 pm Save HistoryExam AssessmentPlan of Care CounselingCoordinationPsychotherapy Justification for Diagnoses, including Rule-Out Considerations Diagnoses [Diagnosis from Axis I/II from Dx Record] Update Dx or Update GAF Only ? [Diagnosis from Axis I/II from Dx Record] [Diagnoses from Axis III, IV, V from Dx Record] Improved Stable Worsening New Px Add’l Workup Planned Dx

17. Standard MHCD form header w/ consumer info Evaluation and Management MHCD Guidelines: In general, risk depends on both the problem and/or the management options selected. Select High risk if there is: one or more chronic illness with severe exacerbation, progression, or side effects; Acute or chronic illnesses that pose a threat to life or bodily function; Drug therapy requiring intensive monitoring for toxicity Select Moderate risk if there is: One or more chronic illnesses with mild exacerbation, progression, or side effects; Two or more stable chronic illnesses; An undiagnosed new problem with uncertain prognosis; Acute illness with systemic symptoms. Prescription drug mangement Select Low risk for: Two or more self-limited or minor problems; One stable chronic illness Acute uncomplicated illness OTC drugs Select Minimal risk for: One self-limited or minor problem Data to be Reviewed SaveCancel Done Finish Last Saved - 4:04 pm Save HistoryExam AssessmentPlan of Care CounselingCoordinationPsychotherapy Review and/or order clinical lab tests Review and/or order tests in the radiology section of CPT Review and/or order tests in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than consumer Review and summarization of old records and/or obtaining history from someone other than consumer and/or discussion of case with another health care provider Independent visualization of image, tracing, or specimen itself (not simply review report) Description of above selected elements Assessment of Risk [Dropbox with Minimal, Low, Moderate, High] Data Dx

18. Standard MHCD form header w/ consumer info Evaluation and Management SaveCancelFinish Last Saved - 4:04 pm Save HistoryExam AssessmentPlan of Care CounselingCoordinationPsychotherapy Plan of Care [Active Medication from OrderConnect] Referrals, next appointments, and other follow-up Agency Medications Add Another Med [Non-Agency Medication from OrderConnect] Non-Agency Medications Add Another Med Reload OrderConnect X X X X X X

19. Standard MHCD form header w/ consumer info Evaluation and Management SaveCancelFinish Last Saved - 4:04 pm Save Select the desired E/M Code from the list of allowable codes [Calculated code] [Next lower code] [etc] [Regular Event Screen (like RestateSAL)]

20. Standard MHCD form header w/ consumer info Evaluation and Management SaveCancelFinish Sign Report screen. Make all the other screens’ content pretty for printing