Update Your Calendar Hours

1. Hover over the User icon at the top right and click on Practice Settings. The Practice Settings page opens.
2. Click Calendar Settings. The Calendar Settings page opens.
3. Click Schedules. The Schedules page opens.
4. Select your name.
5. Click Add Time Slots
   • Time Slots: For any weekday time slots, please make sure you name them “Weekdays“. For any weekend time slots, please make sure you name them “Weekends“. Enter the Start date in the Start box, and the hours in the “From” and “To” boxes. Fill out the rest of the form accordingly. 
   • The Days of the Week drop-down defaults to “Daily (Monday to Friday)”. If you would like a different option, please select “Custom” in the drop-down menu, and select the particular days you would like to add.
   • The Service Location box can be left unfilled, unless you have different hours for each service location.
   • You can then save the dialog box.
6. Click Save & Finish when finished.
7. You can edit/change this at any time, and it’s live as soon as you save it.

Join a Telehealth Meeting

Providers should join the telehealth visit from the Dashboard (Dashboard is an option on the Platform  icon) to be granted host permission. This will give the providers the ability to approve or deny participants access to the visit room. Click “Join” on the Scheduled telehealth appointment. The video appointment opens in a new browser window.

Note: The button to join is accessible for all users in the practice. It displays 30 minutes before the appointment start time and remains available until 2 hours after the appointment end time.

Providers can also join the telehealth visit by directly accessing their Telehealth URL. However, they must be logged into Tebra using the same web browser to be granted host permission.

Create A Clinical Note

Beth Psychiatry uses 2 primary note types:

1. • “Psych Initial Evaluation – Beth”: For a patient’s initial assessment
   • “Psych Progress – Beth”: For a patient’s subsequent appointments

A new clinical note can be created from three different locations: the patient’s appointment on the Dashboard, the patient’s Facesheet, and the Notes tab. It is recommended to create the note from the patient appointment to auto-populate appointment details.

1. Hover over the Platform  icon and click on Dashboard.
2. Click the In Office tab. All patients with an in-office status display.
3. Click on the patient’s appointment to view the appointment card.
4. Click Create Clinical Note. Select one of the two note types mentioned above (i.e. “Psych Initial Evaluation – Beth” or “Psych Progress – Beth”)

Document A Clinical Note

CC and HPI (History of Present Illness)

• The Chief Complaint (CC)section: Click on the section header to add or modify the note using a short description of the patient’s chief complaint.
  • Please note that you can design your own text shortcuts for this section that make note entry easier for you (and you only have to do this one time):

• Access Text Shortcut
  • Hover over the User icon and click on My Settings. The My Settings page opens.
  • Click Text Shortcuts. The Text Shortcut page opens.
• Create New Shortcut
  • Click +New. The Define New Shortcut pop-up opens.
  • Enter the shortcut Name.
  • Enter the shortcut Text.
  • Click Create. The text shortcut is added to the Text Shortcuts list.

• The HPI section should contain your full assessment of the patient. Click on the HPIsection header to add notes using free-form text (which we recommend in this section), Text Shortcut, or Template. To populate using a template, click Template. The Default system template list opens.
  • You do have the option to create your own additional text shortcuts to make charting more convenient for you.

Medications

The patient’s active medications populate in the note from the patient facesheet. From within the note, perform and document a medication reconciliation. If necessary, add active medications, discontinue medications, or retrieve medication history. Review the Plan section (below) to learn how to prescribe new medications.

1. Click on the Medication section header. The Medications pop-up window opens.
2. Medication Reconciliation: Obtain and verify the patient’s active medications. Then, document the medication reconciliation.
   • Select Performed or Excepted – Medical Contraindication from the Medication reconciliation drop-down. The name of the user who performed the medication reconciliation, and date and time it was last updated displayed.
3. + Med List: Click to add the patient’s past and present medications.
4. Discontinue Medication: If applicable, select the medication(s) and click to discontinue the medication(s).
5. Retrieve Med History: Pull the patient’s medication history from Surescripts with their consent and copy the medications to the Active or Discontinued medication list.
6. Click Close when finished.
7. Click the refresh icon within your note to view an updated Medication list.

MSE

If normal, click on “Template” and select “Normal MSE”. Then select “All Normal”. Finally, select close at the bottom of the first drop-down menu.

Review of Systems

If systems are normal, we recommend entering the following information:

Constitutional: No fever. No weakness/fatigue. Eyes: No vision loss. Ears, nose, throat. No sore throat. Cardiovascular: No chest pain Respiratory: No shortness of breath. Gastrointestinal: No abdominal pain. No nausea. Genitourinary: No dysuria. Musculoskeletal: No pain. Integumentary: No rash Neurological: No headache. No dizziness Hematological: No easy bruising Endocrine: No heat or cold intolerance

You are also free to edit the statement as you see fit or enter something entirely different. You can create a “Text Shortcut” to enter this information, so you do not have to type/copy+paste it every time.

• Access Text Shortcut
  • Hover over the User icon and click on My Settings. The My Settings page opens.
  • Click Text Shortcuts. The Text Shortcut page opens.
• Create New Shortcut
  • Click +New. The Define New Shortcut pop-up opens.
  • Enter the shortcut Name.
  • Enter the shortcut Text.
  • Click Create. The text shortcut is added to the Text Shortcuts list.

Psych Intervention

If you provided Psychotherapy and Medication Management, we recommend entering the following information:

• Psychotherapy and Medication Management.

Supportive Psychotherapy:  Encouraged the client to discuss their feelings openly and provided a safe space for expression. Validated the client’s emotions and experiences, normalizing their responses to difficult situations. – Affirmed the client’s strengths and resilience, highlighting their progress throughout their mental health journey. – Employed active listening techniques to validate the client’s experiences and concerns. – Facilitated a strengths-based approach by focusing on the client’s positive qualities (great insight) and achievements. – Empathetically acknowledged the challenges the client is facing.

You are also free to edit the statement as you see fit or enter something entirely different. You can create a “Text Shortcut” to enter this information, so you do not have to type/copy+paste it every time.

Tests

• Enter the scores for both tests – as recorded in the “Documents” section on the left side of the page (PHQ-9 & GAD-7 responses are in this section) – and record the scores in this section.

DSM-5 (Diagnoses)

Patient’s diagnoses can be entered via free text or via the Template. To use the template:

• Click on the Template icon, select the diagnosis category, select diagnosis, and then select the severity/specifiers

Plan

Enter your plan of treatment. If you use AI tools, please assess the text for correctness.

Patient Education (optional)

Provide patient education by sending the documents to the Patient Portal or print a copy in-office.

1. Click on the Plan section header.
2. Click Patient Education. The Patient Education pop-up window opens.
   • Patient education documents related to the patient’s problems, medications, and labs auto-populates. If necessary, use the search bar to find additional documents.
     • To preview the content, click on the document name.
   • Hover over the document name and click the basket icon. The patient education is added to the cart.
     • If necessary, repeat to add additional patient education.
   • Optionally, click the note icon to include additional comments from the patient.
   • Provide documents by sending and/or printing the patient education:
     • To send the patient education to the Patient Portal, click the send icon. The Prescribed Patient Education confirmation window opens. The documents are now available in the patient’s portal.
     • To print the patient education, click the print icon. The Prescribed Patient Education confirmation window opens, and a PDF of the patient education opens in a new browser tab. Use the browser printer function to print the document.
   • Click Close on the Prescribed Patient Education confirmation window.
   • Click X to close the Patient Education pop-up window. The document names of the patient education populate in the Plan section.
3. Click X to close the Plan section.

Save Note

Click “Save and Close” at the bottom right corner when done. Save the note without a signature to continue editing. To finalize the note, providers can sign the note or request a co-sign.

• To allow additional revisions to the note, click Save & Close. The note is saved and the status is Open.
• To finalize the note, click Sign. The note is saved and the status is Signed.
  Note: Only providers can sign a note.
  • To request a co-sign, click the up arrow and select Sign and request Co-sign. The Request Co-Sign pop-up window opens. Select the co-signing provider and click Sign & Notify.

Capture Charge – Send to Billing

1. Click Capture Charge. The Charge Capture page opens.
2. Patient Information: Review and verify the patient demographics.

1. • Patient Alert: The patient alert displays, when documented.
   • Patient Demographics: The patient’s name, date of birth, and gender displays.
   • Insurance Case: The patient’s Primary, Secondary, and Conditions information displays based on the selected insurance case from the associated appointment.
     • If an appointment is not associated to the note, the patient’s primary insurance case is selected.
     • If applicable, select a different insurance case from the Insurance case drop-down.
   • SALT (Same As Last Time): To copy the Referring Provider, Diagnosis and Procedure codes from a previous charge, click SALT and select the previous charge date/provider from the drop-down list. Then, complete the charge as necessary.
2. Visit & Provider Information:
   • Date of Service: The date of service from the note is selected.
     • To use a date range, click to select “Use date range”. Then, enter the End Date.
   • Service Location and Place of Service: The service location from the associated appointment is selected. The place of service auto-populates based on the selected location.
   • Visit mode: The appointment mode from the associated appointment is selected.
     • If an appointment is not associated to the note, “In-Office” is selected by default. To indicate this charge is for a telehealth visit, select “Telehealth Visit”.
3. Diagnosis Codes
   • Enter the diagnosis codes (favorite the ones you use frequently, so they are easy to find when doing future notes ) for your visit
4. Procedure Codes – How you get paid (favorite  the ones you use frequently, so they are easy to find when doing future notes  )                            
5. Click the “Send To Billing” button in the lower-right corner of the page.

e-Prescribing (eRx) Enrollment

1. Hover over the User icon  and click on Practice Settings. The Practice Settings page opens.
2. Click Clinical on the left menu. Additional setting options expands.
3. Click eRx Enrollment. The eRx Enrollmentpage opens.

Prescription Monitoring Links

Electronic databases that collect, track, and store reported dispensing data on Schedule II-V controlled substances, selected drugs of interest, and other health information on a patient basis. The ILPMP is a clinical support tool used to help ensure safety in prescribing and dispensing.

Arizona: https://pharmacypmp.az.gov/pmp-users

California: https://cures.doj.ca.gov/login?callback=%2Fdashboard

Florida: https://florida.pmpaware.net/login

Georgia: https://georgia.pmpaware.net/login

Illinois: https://www.ilpmp.org/CDC/login.php

Indiana: https://indiana.pmpaware.net/login

Kentucky: https://www.chfs.ky.gov/agencies/os/oig/dai/deppb/Pages/kasper.aspx

Maryland: https://www.crisphealth.org/applications/prescription-drug-monitoring-program-pdmp/

Michigan: https://michigan.pmpaware.net/login

Missouri: https://missouri.pmpaware.net/login

New Mexico: https://newmexico.pmpaware.net/login

New York: https://commerce.health.state.ny.us

Ohio: https://ohio.pmpaware.net/login

Oregon: https://oregon.pmpaware.net/login

Texas: https://texas.pmpaware.net/login

Virginia: https://virginia.pmpaware.net/login

Washington state: https://doh.wa.gov/public-health-provider-resources/healthcare-professions-and-facilities/prescription-monitoring-program-pmp

Washington D.C.: https://districtofcolumbia.pmpaware.net/login

Wisconsin: https://pdmp.wi.gov/