Progress Note (Re-Eval)

In this Article

  1. Understanding the Actions Menu at the top
  2. Completing the Progress Note (Re-Eval)
  3. Approve and Send - Fax and Email (Email will be available on Oct 17, 2020)
1

Understanding the Actions Menu at the top

Inside of the Progress Note, there is a Action Menu at the top right hand corner: 
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This is broken down by the following actions:
Delete This will remove the document. (Can only be accessed in the Edit stage of the document)
Previous Goals This will give you a pop-up of previously goals for the patient in this Chart or a different chart.
Daily Note -> Create from PN This will map the information from the Progress Note into the Daily Note.
**If the Action Menu only states Daily Note, this means the daily note was already started
Experience Log Access to the classic Experience log
Flowsheet Access to the new Flowsheet
View Patient This will give you a pop-up with patient information including demographics, contact log, and more! You will also be able to access and edit the patient from the pop-up
Templates This will give you access to the classic and custom templates to add to the document if it was missed on the create screen.
General Store This will bring you into the General Store linked to this patient to create an order during the appointment.
Outcomes This will bring you to the outcome selection to be linked to this appointment.
Preview This will give you a PDF preview of what the final document will look like when approved.
Chart You will have a couple of selections from this area.
  • You will be able to Change the chart if the wrong one was schedule. 
  • You will be able to Edit the chart to update Dx codes or information that may need to be linked.
Approve This will finalize the documentation. Once approved, you will be able to add an addendum if needed.
Approve & Send This will finalize the document and allow you to attach a cover sheet to send to the referring provider.


2. Completing the Progress Note (Re-Eval)

There are several ways to access the documentation. For this article, we will be using the hover over on the schedule. The ability to that the documentation will be available one the appointment has been checked in (CI).
If you are interesting in other ways please check out this article: Ways to Access Documentation

Once the appointment is checked in, hover your mouse over the appointment to view the documentation that is available. Click on Progress Note:

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When starting a progress note please make sure there is a therapist listed in the therapist field. If the therapist field is left blank you will receive an error message.

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You can choose a couple different options for your Progress Note. 

  • Scratch Using Template: Means you can choose from Classic and/or Custom Templates.
  • Previous Document: Means you can choose from a previous document from the same or different patient and copy that document into your current Progress note (great for bringing the Evaluation, Daily Note, or prior Progress Note forward)


Since this is a new patient, this article will be using the Previous Document option:

  •  Red: Select for Creating From Previous Document
  • Blue: The patient will automatically select
  • Green: Select the Appointment you would like to copy from. This will pre-populate the data to be updated for the Plan of Care

Click Create Progress Note to start documentation.

You then have a couple of options, you can scroll down and see everything or you can click each section in the red box. All custom templates, outcomes, and classic templates select on the original document will populate into today's visit.


If you need additional templates, you can use the Action Menu -> Template to add classic and custom templates:



You will want to fill out the documentation in coordination with the set up of the account. There is functionality at the practice level to make fields Options, Required, or hidden. 

If you sent outcomes to the patient they will flow into the middle of the progress note.

Outcomes From Portal:

  • To preview without Linking the outcome, click on the Magnifying glass. This will open a new page to review the Outcome that was completed by the patient.
  • To Link the outcome to the document and have the score populate on the preview, click on the name of the Outcome and select Link from the drop down:

If the patient did not fill out the Outcomes prior to the visit, you can either use the one added on the last document at the top. This will populate their old answers that can be updated for this visit:

Or from the Action Menu -> Outcomes:


This next screen will allow you to select the outcome that you want to add the documentation and walk through the questions with the patient. 

**Please Note: if you do not see an outcome you use in your office, please email  support@heno.io with the PDF and they will add it

Follow the instructions at the top of the outcome and ask the questions to the patient:

Once the outcome has been completed and approved, it will take you back to your progress note with an approved label on it:

Updating the Plan and POC in the Patient's chart:

You will be able to select if you would like the Plan of Care to do one of the following:

  • Replace: This will replace the current Plan of Care inside the patient's chart (Date and Visit count will change)
  • Update: This will add the new Plan of Care to the current one (Update the date and Add the new visits with the old visits) - Most recommended for reporting
  • Do note Update: This will allow you to keep the current Plan of Care with no changes

You will now have access to complete the following:

If you will not be linking CPT codes to the experience log/flowsheet or creating a Daily Note, you can go into the Charges tab of the Progress Note. Click on the Add/Edit CPT codes to start the billing for the appointment:

Once you have completed your Evaluation you can use the Approve the Document to Finalize the Document:

3

Approve and Send - Fax and Email

If you are sending this to the referring provider, Click on Approve and Fax:

This will bring you to the Send page with the referring provider linked with their defaults. You will be able to add a Cover Sheet (Quick Texts can be created for this) and send via fax or email:
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Please keep in mind if you are emailing your documents that your referring physicians cannot reply to these emails and we do not support AOL and Yahoo Email Addresses at this time.
Please let us know if you have any questions with this article at support@heno.io

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Last updated on June 4, 2021