Instructions on completing a basic EHR progress note and charge slip are below.
- Log Into the EHR Side of Psybill. Make sure the EHR box is checked on the login page.
- You should see your patients on the schedule to the left side of the screen. Start with the first patient. When you are ready to start a note, click on their name, and click “Patient Note”.
- This will open the patient’s chart to a new note, attached to the date you were on. The template will auto populate to a Progress Note if the appointment was in your Scheduler as a normal 60 minute appointment. If it was in your appointment as a New Patient appointment, it will auto populate to an Assessment.
- You can change the template if you need to, such as for billing a No Show/Cancelled Appointment. Full instructions on billing no shows is here.
- Once the note template is selected, you will see the corresponding tabs populate above. Click on the first tab to begin documenting. Fields highlighted in yellow are required fields. Navigate through each tab (Progress, Update MSE, and Suicide, Harm, Psychosis Eval) documenting what’s needed. Not all the fields will be necessary or relevant. Use your best clinical judgment as you move through the note. Save your note frequently throughout by selecting the “Save” button in the top left corner.
- The Long Term Treatment Goals, and subsequent Treatment Plan boxes, will need to be filled out entirely the first time you complete a note for a patient. The next time, the boxes will populate from your last note. You can edit them as needed. If you start with an Assessment note, the next progress note will auto fill from the Assessment in these boxes.
- The Diagnosis segment allows you to select from Pick Lists, or type in your own. Click the “ICD” icon, then “Pick Lists” to see the options. Once you find the code you need, click on it and it will populate above. Next, click “Copy” and it will populate to the Diagnosis yellow box.
- To save it for future visits, click the Save icon and it will pop up to tell you that it’s been saved to the patient’s problem list.
- To pull the same diagnosis from the last time you did a note, all you need to do is click the Down arrow icon, and then click Copy and it will populate.
- At the bottom of the Progress tab you will see CPT code options with checkboxes. There is a section for in person services, and a section for telehealth services. You will need to select the corresponding checkbox. Only check more than one box if you are using an add on code, such as 90875. The code selected is going to auto-populate into your charge slip at a future step.
- Once you are done with your note, click “Sign” at the top. It will prompt you to enter your Sign Off Password. This is your birthday (for example, if your birthday is Sept 20th, it will be 0920). Once your password is entered, click “Sign”. Once your note is signed, you cannot edit it. However, you can add an Amendment (also known as Addendum) to the note if needed. Additional instructions on doing so can be found in the Therapist Portal.
- After clicking “Sign”, the next screen will automatically populate a charge slip. Your CPT and diagnosis codes selected in your note will automatically populate into this charge slip. Double check your CPT code and diagnosis code. Then click the “Sign” at the top.
- It will show you a submitted charge slip after you click “Sign”. Once it is submitted, you can click “Dashboard”, and go to the next patient.
