Evaluation and Management Note

1. 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. Evaluation and Management Note

2. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Coordination Plan of Care History Assessment Exam Counseling Psychotherapy Chief complaint CC. 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. HPI. ROS. PFSH. [Text required to finish section.] 1000 Finish Save Cancel

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

4. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Plan of Care History Assessment Exam Counseling Coordination Psychotherapy History of Present Illness CC. Chronic Condition [Brief/Extended] Acute/New Condition HPI. [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) ChronicCondition ROS. PFSH. Status update entered on MM/DD/YYYY Update text Status of Condition [Show all conditions in scrolling box] Save Finish Cancel

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

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

7. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Plan of Care History Assessment Exam Counseling Coordination Psychotherapy [Pertinent/Complete] Past, Family, and/or Social History CC. Family History 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. HPI. Past Hx Entered on MM/DD/YYYY Narrative family history text entered on prior date ROS. Family Hx SocialHx PFSH. History update entered on MM/DD/YYYY Update text History Reviewed and Confirmed Updates/Interval History Save Finish Cancel

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

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

10. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Plan of Care History Assessment Exam Counseling Coordination Psychotherapy Musculoskeletal [Problem Focused/Expanded Problem Focused/Detailed/Comprehensive] Const Not Assessed Normal Abnormal Musc Muscle Strength and Tone Gait and Station Psych [AIMS Due/Overdue from Task List] [Result from AIMS] eCET AIMS Finish Save Cancel

11. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Plan of Care History Assessment Exam Counseling Coordination Psychotherapy Psychiatric [Problem Focused/Expanded Problem Focused/Detailed/Comprehensive] Const Not Assessed Normal Abnormal Musc 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 Psych Finish Save Cancel

12. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Assessment Plan of Care History Exam Counseling Coordination Psychotherapy Counseling • 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. Minutes spent during session on Counseling Save Finish Cancel

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

14. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Coordination Plan of Care History Assessment Exam Counseling Psychotherapy Psychotherapy Psych 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]. 00 Minutes spent during session on Psychotherapy IntCompl Save Finish Cancel

15. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Coordination Plan of Care History Assessment Exam Counseling Psychotherapy Interactive Complexity Psych • Guidance from AMA: • Psychiatric procedures may be reported “with interactive complexity” when at least one of the following is present: • 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. • Caregiver emotions or behavior that interferes with the caregiver's understanding and ability to assist in the implementation of the treatment plan. • 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. • 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. No Yes Interactive complexity present? IntCompl Justification of complexity Finish Save Cancel

16. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Assessment Plan of Care History Exam Counseling Coordination Psychotherapy Assessment Show if not new Add’l Workup Planned Dx New Px 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 Pxthis 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. Diagnoses Improved Stable Worsening Data [Diagnosis from Axis I/II from Dx Record] [Diagnosis from Axis I/II from Dx Record] [Diagnosis from Axis I/II from Dx Record] [Diagnoses from Axis III, IV, V from Dx Record] Update Dx ? or Update GAF Only Justification for Diagnoses, including Rule-Out Considerations Save Finish Cancel

17. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Assessment Plan of Care History Exam Counseling Coordination Psychotherapy Data to be Reviewed Dx • 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 Review and/or order clinical lab tests Data 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] Done Finish Save Cancel

18. Standard MHCD form header w/ consumer info Save Evaluation and Management Last Saved - 4:04 pm Assessment Plan of Care History Exam Counseling Coordination Psychotherapy Plan of Care Reload OrderConnect Non-Agency Medications Agency Medications X X [Non-Agency Medication from OrderConnect] [Active Medication from OrderConnect] X X [Non-Agency Medication from OrderConnect] [Active Medication from OrderConnect] X [Non-Agency Medication from OrderConnect] [Active Medication from OrderConnect] X Add Another Med Add Another Med Referrals, next appointments, and other follow-up Finish Save Cancel

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

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