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Form Details

• Form Properties
  1. Form Title: E&M + Psychotherapy Progress Note
  2. Start from an Existing Form – No
  3. Copyrighted Form – No
  4. Billable Progress Note – Yes
  5. Have multiple versions open at same time – No
  6. Open Blank on new version – Yes
• Required Fields – Yes
• Lookup Tables – Yes
  1. Code will pull from Facilities.
• Pre-Fill Logic – Yes
  1. Diagnoses on Axis Tab will prefill from diagnosis listed in ICD 10 Diagnosis Table (Administration → ICD 10/DSM 5) or most recent signed and locked Diagnosis form/tab.
• Fill to Logic – Yes
  1. Diagnosis tab will fill any new Diagnosis or Assessment forms and the read-only Diagnosis tab in Patient Details.
• Signatures
  1. Physician Signature
     • Sig type: Physician
     • Route-to is available
     • Signature locks form

Session Info Tab

1. Select appropriate code for this session.

History Tab

1. Note Chief Complaint/Reason for Encounter for E&M.

Review of Systems Tab

1. Document Review of Systems & Active Medical Problems.

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Psychiatric Specialty Examination Tab (1 of 2)

1. Document results of Psychiatric Specialty Exam as directed.

Psychiatric Specialty Examination Tab (2 of 2)

1. Continue to document results of Psychiatric Specialty Exam as directed.

Axis Tab

1. Add/edit the patient’s Diagnosis.

Medical Decision Making Tab

1. Note medical decisions and treatment plan as directed.

Psychotherapy/Signatures Tab

Signature Credentials (see Credentials)

1. Physician Signature
   • Sig type: Physician
   • Route-to is available
   • Signature locks form

History Tab

1. No input. History of previous sessions will display.

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