1. Go to Notes (bottom tab) -> New Note (bottom left side of screen)-> Ambulatory Care New Patient Note (Make sure to select the new patient encounter)
2. Click Ok and this will generate a blank note
3. Bottom left side of screen click on Templates and click on the template you have for new patients (whoever is training you will provide you with a template you can then customize)
4. After you see the patient and are done with the note the following needs to be done to close an encounter:
a. RTC Order (this should be done while you are seeing the patient, so the patient can make their next appointment at checkout) - (chance to use Quick orders - click Here)
b. Labs for future appointment
c. PACT Plan of Care (must be done once per year and for all new patients)(chance to use a Template - click Here)
d. Sign Note and Encounter the note
5. To edit the encounter, while the note is open click on Encounter on the bottom left side of the screen. The following elements are needed for the Encounter to be complete:
a. Current provider (PCP (you) are the primary provider, make sure this is selected)
b. Service connections as applicable
c. Type of Visit
i. Select NEW PATIENT
ii. 99203 (Detailed) is the minimum we do, most are 99204 (Comprehensive, Moderate MDM)
d. Under the 2nd tab titled “diagnosis” select ALL dx that you addressed in your visit, there is a pre-completed list of PC COMMON DIAGNOSIS you can
select from. If the problem you are managing is NOT on there select “other diagnosis” and search it.
e. Since this is a new patient the problem list will be empty, once you select your problems, highlight them all and click “Add to problem list” on the side of the screen, this will prompt you to find the SnoMed Code for the problems so that they can be added to the problem list.
f. Click Ok when you are done and the diagnosis and problem list will be saved, the next time you see the patient you can select their problems from the problem list and add new problems if relevant.