[Navigation] Patient > Patient Contacts
[Accordion] Overview
The Patient Contacts module serves as a centralized hub for recording, tracking, and reviewing interactions throughout a patient's care journey. This tool provides a streamlined workflow for staff to document a wide range of patient-related activities, ensuring that no detail, from a routine check-in to a critical medication change, is lost.
By maintaining a chronological treatment history, the module allows clinicians to instantly reference past contacts, helping them identify patterns and maintain clinical consistency.
Note: The terminology "Appointments" relates to the the clinical record documented for an encounter. These are separate from (although related to) the "Events" you place on the Schedule, which are more like placeholders for future appointments.
[Tip] If you see different labels than what is shown in this article (e.g., Patient vs Client), your system may have Custom Labels applied. You can verify and update these by locating "Custom Labels" in the Global Search.
[Permissions] To edit and create Patient Contacts, the Staff members must have Full access to the Patient Contacts Module [Staff > Staff Info > System Permissions > Patient Contacts]
[Accordion] Getting Started
The Patient Contact module starts by displaying the patient lookup.
- Select the category buttons to filter the records displayed based on the selected option. By default, you will see options for:
- Pending (shows results where the Appointment Status is set to Pending)
- Do Not Bill (shows results where the Billable Status is set to Non-Billable)
- Mark for Review (shows results where this option is checked in the Progress Note)
- Missing/Unlocked Note (shows results where a Progress Note is missing or unlocked)
- Locked (shows results where a Progress Note is locked)
See Advanced Filter for an explanation about further filtering options
- Click/Tap on [[img:add>> lbl:New Appointment]] to create a new Appointment for the selected patient.
- Click/Tap on [[img:add>> lbl:New Collateral]] to create a new Collateral for the selected patient.
Tab: Appointment Details
- Appointment Details:
The Appointment Details section is the operational core of the appointment. By precisely defining these fields, you ensure the appointment is correctly reflected and prepared for subsequent billing and reporting.
Key Appointment Components
- Status: Lets you define where in the appointment workflow the record is. Appointment Status entries can be configured at Utilities > Maintenance > Appointment Status
- Date & Time: Records the start and end dates, exact appointment times, and the total billable hours to be tracked for reimbursement
- Clinician & Supervisor: Designates the primary Clinician and, if required, the Supervisor responsible for the session
- Program & Place of Service: Links the session to a specific Program and specifies the Place of Service (e.g., Main Office, Patient Home, Telehealth) to assist with documentation and claim processing
Service Details
The Add Service and Quick-Select Service options allow you to link specific billable codes to an Appointment. Once selected, these Services are organized into a clear, structured table that serves as the foundation for your billing and productivity tracking.
The table provides a real-time overview of the Appointment's billable components:
- Service: Clearly labels the type of Service being provided (e.g., Individual Therapy, Group Session, or Case Management). Service entries can be configured at Utilities > Maintenance > Service Input.
- Units: Automatically calculates the quantity based on the session duration or predefined flat rates. Time-Based Services can be configured at Utilities > Maintenance > Service Input.
By finalizing this section, you ensure that the clinician's activity is accurately captured and that the administrative team has all the data needed to generate clean claims.
- Billing Details:
The Billing Details section contains all billing-related information for the appointment. It includes Billable or Non-billable status, Session #, treatment type, and an option to override the unit price. It also includes a Calculate function, clinical summary field, and GAF score (1–100) for documenting patient functioning.
- Diagnosis:
The Diagnosis section ensures that every interaction is clinically justified by linking the appointment to the patient’s specific health conditions. This section is essential for establishing "medical necessity," a core requirement for both clinical record-keeping and insurance reimbursement.
Managing Diagnostic Data
- Assign & Link: Choose from the patient’s existing diagnosis list to associate specific conditions with the current session.
- Add/Edit: If a new concern arises during the appointment, you can create a new entry or update current ones directly within this interface.
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Clinical Indicators: Beyond ICD-10/DSM-5 codes, you can record specific assessment scores, such as:
- GAF Scoring: Global Assessment of Functioning to track overall psychological health.
- Risk Assessment: Immediate safety flags (e.g., self-harm or ideation) relevant to the session.
- Payor Details:
The Payor Details section is used to manage insurance coverage and authorization information required for billing and claim submission.
Primary Payor:
The main insurance is responsible for covering the service. Claims are first submitted to this payor, and authorization details are validated here.Secondary Payor:
An additional insurance that covers remaining balances after the primary payor has processed the claim. It is used when dual coverage is available.Tertiary Payor:
A third-level insurance is used when both primary and secondary payors have been applied. It helps cover any remaining eligible charges.
Each payor section also includes coverage type, authorization number, authorization revision number, and authorization actions. It also provides Auto-Insert and Search options to quickly retrieve and apply existing authorization details.
Collect Signatures:
The Collect Signatures section is used to capture electronic signatures, confirming that the documented information has been reviewed and acknowledged by the appropriate parties.
- Patient Signature: Records the patient's electronic signature to indicate their acknowledgment or approval of the appointment, services provided, or associated documentation.
- Other Signature: Records the electronic signature of another authorized individual, such as a guardian, caregiver, legal representative, or witness, when an additional acknowledgment is required.
Tab: Create Progress Note
[Anchor:ProgressNoteForms]
Progress Note Forms: Quick Search helps you quickly locate and access the required note from your entire collection. There are several built-in Progress Note forms, listed below, that can be used alongside the Custom Form Progress Notes you create.
- SOAP Note: A structured clinical note used to document patient visits, including Subjective patient-reported information, Objective clinical observations, an Assessment of the findings, and a Plan for next steps in treatment.
- SNAP Note: A simplified clinical documentation format that includes Subjective patient information, identified Needs, a clinical Assessment, and a Plan for treatment or follow-up.
- DAP Note: A clinical documentation format that organizes information into Data, Assessment, and Plan sections. It records relevant patient information and observations, the clinician’s interpretation of the information, and the planned interventions, recommendations, or changes in treatment.
- Personal Therapy Progress Note: Documents the content and outcome of an individual therapy session, helping track behavioral, emotional, or cognitive changes and supporting ongoing treatment planning.
- Standard Progress Note: Used to document routine clinical sessions, capturing the patient’s status, the clinician’s assessment, and the plan for continued care. It helps ensure key clinical details are recorded clearly and consistently.
- Specialty Progress Note: Designed for programs with unique documentation needs, such as psychiatry, substance use, or crisis services. It includes specialized fields to ensure program-specific information is recorded accurately.
[Accordion] FAQs
[Q] I don’t see the Patient Contacts module. Do I need special permissions?
[A] Yes. Staff must have Full access to the Patient Contacts module under [Staff > Staff Info > System Permissions > Patient Contacts]
[Q] How do I add multiple Services to one appointment?
[A] In the Service Details section, click on [[img:add>> lbl:Add Service]] or [[img:draw>> lbl:Quick Select Service]] and add each required service. All services will appear in the table for that appointment.
[Q] What does “Change Phase of Current Record” mean?
[A] Change Phase of Current Record lets you move the Appointment Record to the right Treatment Phase.
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