Schedule Layout

Overview

• Upcoming: Patients who have an appointment that day will show up under this section. The term, ‘appointment card’, is used to describe each appointment seen on the schedule.

• Waiting Room: Patients who have started the check in process will show up under this section. The yellow dot indicates the patient is in the process of checking in.

• In Progress: Patients who are checked in & waiting for the provider to join and/or are in the call with the Clinician will show up under this section. The current visit status is shown at the top of the appointment card. The yellow dot indicates the patient is completed with Check In and ready for the clinician to start the visit.

• Pending Results: This only applies to in clinic visits.

• Ready for Check-out: This only applies to in clinic visits.

• Pending Sign off: Patients who have completed their video appointment and need their charts signed off by the clinician will show up under this section.

• Completed: Patient charts that have been signed off by the clinician or automatically by the billing provider will show up under this section.

• No Show / Canceled: Patients who have canceled or visits were manually marked as No-Show will show up under this section.

Workflow for starting and completing virtual appointments: https://www.loom.com/share/319a8b5db16842f2bffd3eacc362d902?sid=a54cd07f-9804-41b6-8a1e-4d1032a43459 (opens in a new tab)

Check-in

Guardrails: The provider app will indicate with an asterisk* which fields are required in order to complete check-in.

Overview

1. Click on the patient’s appointment from the schedule and click “Start check in”. Following the order of the fields listed, first click on Patient Information.
2. Patient Information: This section is where one can edit the patient’s race, gender identity, preferred name, and preferred pronouns
3. Patient Cards: If the patient had a previous in person visit, photos will be visible here of the ID.
4. Specialty: The specialty will auto populate here and will depend on which specialty was selected during the booking process. No action is required.
5. Responsible Party: When clicked on, a new window will pop up and there are five options to choose from:
   • Insurance (In-Network)
     • To be selected when the patient is using in-network health insurance for their visit.
   • Insurance (Out-of-Network)
     • To be selected when the patient is using out-of-network health insurance for their visit.
   • Patient
     • To be selected when the patient is uninsured or will be paying for services out of pocket.
   • Worker’s Comp
     • Only to be used in person
   • Organization or School

     • To be used for patients who are a part of the Workplace Health / Employer Paid Services Specialty where the organization or employer is the responsible party for the patient’s visit.

Check-in Insurance (In-Network & Out-of-Network) Workflow

1. Collecting insurance:

   1. Input the patient’s insurance information into the insurance field.
      1. Type in the patient’s name exactly how it is on their insurance card
         • For example, while the patient might’ve made their account under the name “Mike,” their insurance card shows Michael is their first name.
      2. Input their date of birth, as listed on their ID
      3. Type in the patient’s insurance ID number. This is typically on the front of the card.
      4. Carrier Name and ID are the only required fields.
      5. Next, save the information. Clicking save will allow the RTE (real time eligibility) verification to run.
         • Verified Insurance will show a green checkmark.
         • Unverified insurance will provide alerts for the user to correct errors (2x) then display a yellow exclamation and “Not Verified Yet” at the bottom of the digital card
      6. If the insurance could be verified, skip to step 5 and proceed with charging their copay.
      7. If their insurance has been flagged as inactive, follow your clinic's practice for unverified insurance.
   2. Confirming the insurance patient has on file:
      1. After assigning the responsible party, run the eligibility again.
         • To do so, click on the patient’s insurance, click the edit pencil icon. Click save changes and check to see if the insurance could be verified.

2. Unverified Insurance Flow: If their insurance has not verified but the patient has provided an insurance card:

   1. FIRST, re-attempt to input the insurance and correct any errors.

      1. Ensure that the patient’s name is entered in the EMR is as appears on the insurance card.
      2. Verify the patient’s date of birth with their ID
      3. Review the back of the insurance card to confirm that the correct carrier name has been entered
         • Check for a specific insurance plan name and select rather than using the umbrella insurer (For example, selecting Blue Cross Blue Shield of Massachusetts vs just Blue Cross Blue Shield can make insurance verify)
      4. Re-enter the patient’s ID number. Check and double check for any typo’s!

   2. If that still does not work, continue with the check-in flow.

3. Consent Forms: The EHR does not require the consent forms to be completed in order to start the visit.

   1. The patient-facing booking flow will require the patient to sign the consent forms before actually booking their appointment.
   2. In the staff-facing booking flow - where the staff books on behalf of the patient - the consent forms are not required to be signed before actually booking the appointment.

4. Default Credit Card:

   1. If the patient does not have a card on file, you can instruct them to add one to their profile within their account settings.

      1. “Click on the tab that has your first name, click payment, add credit card”

   2. If a credit card cannot or does not need to be collected, a reason must be documented. To do so, click “Skip Collecting Credit Card” and choose an option from the drop down and click save.

5. Charge copay

   1. Click “Charge Copay” in the EMR.
      1. If the patient chooses to pay with a card, proceed with charging the card on file.
      2. Not charging a copay: If no copay is collected, “Skip Payment” should be selected from the payment methods drop down.

         • If the copay shown in the box is $0.00 and the Copay box is CHECKED, select “$0 copay returned from RTE”

         • If the copay is “$0.00”, and the Copay box is UNCHECKED select “Copay unavailable (RTE failed AND no copay info on the insurance card.”

• If an amount is shown but your facility does not collect copay or any amount upfront, select one of the other reasons from the skip options.

Tips/Suggestions:
The amount presented is pulling from the current (latest checked) benefits and you can decide to charge what is presented or charge a custom amount

For example, at Carbon, our policy is the following:
If there is a discrepancy in the amount populating in the EMR via RTE and the amount printed on the insurance card, proceed with charging the amount posted in the EMR. The patient can contact their insurance if they have questions. The patient may be presenting an outdated card.

6. Patient Balance: Click on this field to check for any outstanding patient balance. Collect outstanding balances during check-in.
   • Patient Balances will be shown in red next to the name of the field if the patient has a balance.
   • Please refer to your clinic’s protocol on balance collection to determine if any amount should be collected prior to the visit

Self-pay Workflow

1. Responsible Party: select “Patient”
2. Default Credit Card:
   1. If the patient does not have a card on file, you can instruct them to add one to their profile within their account settings.
      1. “Click on the tab that has your first name, click payment, add credit card”
   2. If a credit card cannot or does not need to be collected, a reason must be documented. To do so, click “Skip Collecting Credit Card” and choose an option from the drop down and click save.
3. Consent Forms: The EHR does not require the consent forms to be completed in order to start the visit.
   1. The patient-facing booking flow will require the patient to sign the consent forms before actually booking their appointment.
   2. In the staff-facing booking flow - where the staff books on behalf of the patient - the consent forms are not required to be signed before actually booking the appointment.
4. Charge for Visit: The box will populate the self-pay cost of the base visit.
   1. For credit card, proceed to charge the card on file.
   2. If the patient would like to pay with cash or check, we can collect cash for the visit copay. Be sure to select “Cash” or “Check” if they are and follow the appropriate workflow to store the cash/check in the clinic.
5. Patient Balance: Click on this field to check for any outstanding patient balance. Collect outstanding balances during check-in.

   1. Patient Balances will be shown in red next to the name of the field if the patient has a balance.

Organization or School

1. Responsible Party: select “Organization or School”
2. Choosing Organization:
   1. Click the Add button
   2. Search for the employer name
      1. If you cannot find the employer, select Employer Pending (please notify Account Manager to add in the employer for future use)
3. Consent Forms: Collect a patient’s written signature on their consent forms.

Triage

Start Triage

1. Click on the patient’s appointment card from the schedule
2. The screen will split into the appointment panel on the left and the patient’s medical record on the right
3. In the appointment toolbar, select “Start visit”

History of Present Illness (HPI) / Chief Complaint

1. Click on “HPI” from the Triage tasks
2. A new screen will appear with the chief complaint listed at the top, followed by several chief complaint variables to address with the patient e.g. duration, onset, progression etc…
3. Click “Save”

Tips/Suggestions:

• You can also access the HPI questions by going into the patient’s case and clicking on the chief complaint title that is found right below the Medical History. If you see just a title with no answers, the patient did not complete this section. Please ask the patient to confirm their chief complaint and work with the patient to fill out the template.
• If you need to change or add additional chief complaints, click on “Add to chart” at the bottom of the patient’s Case
  • In the search bar on the new screen that pops up, type in the main chief complaint
    • The Provider App will find the closest match. For example, if you type in “sore throat”, the app will show a few different templates for sore throat. Choose the option that is tagged with “Symptom” seen on the right side of the chief complaint

Medical History

Select “Medical History” from the appointment toolbar on the left

• On the screen on the right, click the Edit button in the top right corner

Rx Renewal:

For patients that just need a prescription refill/renewal without an encounter follow the steps below:

• Select the medication tab in the patient chart

• Select the medication(s) from the list that will be refilled/renewed.

• Click/tap on the “Renew” button in the top right corner of the medication list. This will generate a new care plan with the medication and the diagnosis code from the previous encounter that the medication was prescribed.

• Make any edits necessary prior to publishing the care plan.

• Every time a prescription is refilled/renewed, it will generate a new case that can be reviewed under the “Cases” tab in the pt chart.

Evaluation

Start Video Call

In the appointment toolbar, select “Call patient”

• This will send a message to the patient to join their video call

Use of AI

The AI scribe places a SOAP or a problem focused more extensive note in the medical decision box capturing pertinent history, physical, and medical decision making (assessment and plan). The AI scribe is able to document the history based on your conversation with the patient. Clarifying confusing statements made by the patient makes the history more accurate.

The clinician must speak out the pertinent physical exam for the AI scribe to document the exam.

The AI scribe will document the assessment and plan from the conversation you have with the patient describing your decision making, plan and follow-up.

If you are performing in-house testing or imaging that can potentially modify the assessment and plan, you can do one of two things:

1. Pause the AI scribe after your initial discussion with the patient regarding the assessment and plan and resume when you return to the patient summarize the results and the plan.
2. Alternately, you can summarize, perform the testing, and press record again when you return to the patient. The scribe will generate a second note with the new information layered onto the existing note, so there will be two notes generated. You delete the old one.

NOTE: that the history, speaking through the physical exam, discussing assessment and plan, don’t have to be performed in that sequence. You can ask questions to gather additional history in the midst of discussing the assessment and plan and the AI scribe will pick up the new information for the history as well as how it may modify the assessment.

The AI scribe does not document a review of systems. A complete Review of Systems is not necessary to document, with the new coding guidelines. If you need to document a review of the system (rare occurrence), you follow the below instructions.

Review of Systems

Click on the Review of Systems section and complete as needed. As mentioned in the HPI section, when selecting positive findings, you may be presented with a nested schema for that finding, where you can click in and provide more information

Physical Exam

Click on the Physical Exam section and complete as needed.

Medical Decision Making

Click on the MDM section and complete as needed.

Creating the Care Plan

Overview
This section will walk you through how to build a care plan and place orders such as prescriptions, imaging and labs.

Click “Start visit” in the appointment panel

• Who should click this?
• Whoever will be rendering the visit should be the individual clicking Start Visit.

Click Add from Existing

• This is the option you can select to add a care plan that duplicates a previous care plan entered into a patient's chart. This can be edited and tailored for this visit.

Click Add New

• This is the option you can select to add an empty care plan

Diagnosis

• Overview
  • This is where you will add all diagnosis codes pertaining to this encounter.
  • How To
    • Click the + Add diagnosis text to add your first diagnosis code. You can search for a diagnosis by the code or the description. Some diagnosis codes may require refinement to ensure the most specific dx code is selected.
    • To add additional codes, click + add additional diagnosis
  • Be advised
    • If there are specific orders that should be tied to certain diagnosis codes, you can create a separate care plan within the same encounter to ensure the dx is associated with the orders.

Patient instructions

• Overview
  • This is where you will write instructions to the patient to read in their Patient App or on the printed care plan.
• How To
  • Click into the instructions section and begin typing
• Be advised
  • This section will be pre-filled if the AI recording function is utilized and can be edited afterwards.

Education materials

• Overview
  • This is where you will insert any links or PDFs of any guidance/education on patient diagnosis and/or further knowledge on the patient’s illness. There are education materials for different conditions already available in the Provider App, but you can also insert your own from reputable resources like Uptodate.
• How To
  • Click ‘Add an educational material’ and there will be suggestions based on the diagnosis code selected. You can search for materials in the search bar, select the option and choose Add in the top right corner.

Medications

• Overview

  • This is where you will add medications administered in the exam room, prescriptions the patient may purchase from you, or prescriptions to be sent to the pharmacy.

• How To

• Click ‘Add a medication’ and you can select from the list of medications presented or search by active ingredient or trade name. If the generic name doesn’t show up, search for the brand name. Complete the medication details shown in the window.

• Ordering in-office vs in-house medications vs external medications: While in the medication details window, select Office as the frequency when you are administering the medication in the exam room. Toggle on in-house pharmacy if the patient will be purchasing the take home medication from your facility. Leave in-house pharmacy toggled off if the medication should be sent to the pharmacy.

• Be advised

  • Drug-Drug Interaction: The EHR will automatically notify you of any potential drug-drug interactions between any medication you order and the medications listed in the patient’s current medications list. The notification pops up at the top of the prescription Details page in an orange sherbet font. You can click on each notification for additional info. You can still proceed with placing the order after reviewing the notification if you determine the benefit outweighs the risk. Note: make sure the patient’s medication list is up to date and free of any medications the patient is not currently taking

  Orders & Tests

  • Overview
    • This is where you input any orders for in-house procedure and tests (excluding labs). Examples of some procedures you may order in this section are EKGs, Ear Irrigation, and Incision & Drainage.
  • How To
    • Click ‘Add an order or test’ and search by a procedure or test name. Select the row of the test and complete the form and press Save.
  • Be advised
    • It is not necessary to complete the entirety of the form when placing the order as users will be prompted to do so at time of service.

Requested Labs

• Overview
  • Here is where you will place orders for any in-house or external labs. On the top left hand side of the search bar, you will be able to filter the labs by in-house versus external labs. Some examples of internal labs are Rapid Flu, Strep and Pregnancy tests.
• How To
  • Click ‘Add a lab request’ and search for a lab test by the code or test name. You can select as many tests as needed in this same window and the selected results will appear at the top of the screen in gray.
• Be advised
  • All external labs should have “PSC” toggled on (green) as true as that is indicating that the patient will be going to the lab’s patient service center to have the specimen collected.

Requested Imaging

• Overview
  • This section is where you can place an order for imaging.
• How To
  • Click ‘Add a medical image request’ and select the Modality and complete the rest of the fields. For any imaging orders that cannot be completed at the clinic and requires the patient to go to an external facility, select No in the In-House section. The order can be e-faxed directly to the facility or given to the patient.

Referrals

• Overview
  • Should a patient require care that extends beyond the services offered at your facility, you can add referrals to the appropriate specialty here.
• How To
  • Click ‘Add a referral’ and search for a specialty. You can define an urgency which will display on the referral PDF. Additionally, you can input notes for the patient or provider about this referral.

Follow-Up Appointment Requests

• Overview
  • These are requests that you will place if you think the patient needs to return to your clinic at a later time. Some examples might be that you request a patient to come back in to have an injury reassessed, labs to be drawn, or return for suture removal.
• How To
  • Click ‘Add a follow-up appointment request’, complete the fields, and optionally you can add a care plan to prepare the follow up appointment.

Automated Follow Ups

• Overview
  • Use this section when you want a message to be automatically sent to the patient after a certain amount of time has passed following their visit. Common follow ups include providers sending messages to their patients 3-5 days after their visit, asking how they are feeling, or inquiring what symptoms are still present.
• How To
  • Click ‘Add an automated follow-up’, select the scheduled date, add a message text, and attach a questionnaire if you’d like.

Charge Navigator

Overview
The charge navigator section is a decision tree to incorporate decision support that will determine the E&M appropriate for the visit. This will pull codes from the chart and automatically add them to the bill.

How to
Click into the Charge Navigator section and complete each section.

Guardrails
If there is a required section not completed, the CPT codes will not be shown at the bottom of the form and the visit will not be able to be completed.

Completing the orders

• Medications
  • How to send a prescription electronically
    • Click the green Fill button
    • Select either Pick Up or Home Delivery
    • Choose the pharmacy
    • Press send prescriptions
  • How to indicate the prescription was called in
    • Click the 3 ellipses (dots) on the right side of the medication
    • Choose ‘called in prescription to pharmacy’
• Orders and Tests
  • How to complete
    • Orders and Tests would only be placed in the Care Plan for In Person Visits
• How to complete external lab orders
  • Select Print Requisitions
  • Choose the Responsible Party
    • Client should not be used for Virtual Visits
  • Click the 1 button to surface the requisition and download to send to the patient
  • Click send lab orders
    • This will send the lab order electronically so it is in the lab’s system
• How to complete an imaging order request
  • Click Print Order Form
  • Download the form and send to the patient in messages
• How to print Referrals
  • Click Generate Referral
  • Search for the practice
    • Enter in the name and fax number if you don’t see the practice as an option
  • If you do not know the fax number, enable that toggle and click Save PDF
  • Otherwise, press send referral
• How to book a follow up appointment
  • Click Schedule
  • Follow the necessary steps