Patient Details is central/shared information regarding patient demographic data and other patient-centric information that that can be seen and accessed across programs. For more the most part, information contained here is data that will flow down to the chart/episode of care level, think data captured on a form. The idea is to capture the data once so that a user does not have to enter that data again on a form. Typical types of data captured in Patient Details include: Demographics, Contacts, Insurance information, Most recent diagnosis, Medication listing, and patient designations/flagging.
Click the tabs below to expand the information on each tab.
Access Level Permission
- Go to Administration > Access Levels.
- Select the existing access level or create a new access level.
- Select the 3rd User Access tab.
- Check the box for any functionalities needed.
- Click Save and repeat for each access level that will be given permission for Patient Details.
Open Patient Details
Patient Details can be found one of two ways:
- From the Day to Day drop-down menu, go to Patient Details.
OR from the desktop menu, if set up in preferences , go to Day-to-Day > Patient Details. See Set Up My Preferences for more information.- Enter the patient name in the search field.
- Enter additional filters (Include Inactive, etc.) to narrow search.
- Enter the patient name in the search field.
- Open the patient chart, click on the patient’s name in the upper left corner.
- My Client List > right-click on the patient's name > Patient Details.
Navigation Links
There are navigation action buttons listed across the top of the Patient Details window. This list describes what each action does.
- Clear will clear any Information entered.
- Save will save any information entered.
- Patient Chart Access will allow you to block a user’s access to all of the patient’s charts.
- Ledger will open the patient’s ledger.
- Patient Receipt will open the receipt window.
- Patient Payment will open the payment window.
- New Chart will open the chart management window to establish a new chart/program.
- Photo will open the window to upload a picture.
- Chart List will open the window to navigate to all of the patient’s charts.
- The Notes drop-down menu will allow the user to create Patient, Billing or Dispensing notes outside of the patient's chart record.
- Drug Screenings will open the Patient Screening Schedule window.
- Wait List will allow the user to add the patient to the wait list.
Name/Address Tab
- Enter the Patient Name: first, middle, and last.
- Enter the patient’s DOB: Date of Birth.
- Check the box for SOF (Signature on File) if the patient signature has been captured on file.
- Check the box for LOE (Language other than English) if the patient is fluent in a language other than English.
- Check the box for Inactive to inactivate the patient.
- Enter the patient’s SSN: Social Security Number.
- Enter a Pseudo SSN if desired. When filled in, this will override the SSN when pre-filling the DCF forms and creating the submission files.
- Select the patient’s Sex from the drop-down menu.
- Select the patient’s Marital Status from the drop-down menu.
- Enter the patient’s Med Rec No, Medical Record Number.
- Click Auto Generate to generate a Medical Record Number when registering for the first time.
- Click Vital Signs to enter the patient’s vitals, ie age, height, weight, blood pressure, etc.
- Check the box for Hold Patient Bills to hold the patient's bills.
- Enter the Email and Telephone Contact information for the patient.
- In the Physical Address tab, enter the address for the patient, including city, state, zip, country, county, founding county, and catchment.
- In the Mailing Address tab, enter a mailing address, if different from the physical address.
- Check the box for Homeless if the patient is homeless and does not have a physical or mailing address.
Additional Demographic Info Tab
- Use the Additional Name/Alias grid to capture all names associated with the client.
- The Name Type selection identifies the record and is referenced by forms that preload the Alias or Mother's Maiden Name field information. The following values are available.
- Previous Legal Name
- Maiden Name
- Alias
- Nickname
- Mother's Maiden Name
- Other
- Select the Preferred Name checkbox on a record to identify the client's preferred name. The checkbox can only be selected for one record at any given time.
- Select the client's Preferred Pronouns from the drop-down menu.
- Select the patient’s Sexual Orientation from the drop-down menu.
- If patient’s sexual orientation is not available in the drop-down menu, enter a description of their sexual orientation in the If something else, please describe field.
- Select the patient’s Gender Identity from the drop-down menu.
- If patient’s gender is not available in the drop-down menu, enter a description of their gender in the Additional gender category/(or other), please specify field.
- Select the patient’s Race(s) from the drop-down menu.
- Select the patient’s Ethnicity(s) from the drop-down menu.
- Enter the patient’s ethnicity if it is not available in the drop-down menu or if the patient has more than 2 ethnicities in the Other Ethnicity field.
- Select the patient’s Religion from the drop-down menu.
- Select the patient’s Preferred Language from the drop-down menu.
- If the patient has Ever Served in Military, select Yes, they have served. Select No if they have not.
- Select the Patient Preferred Method of Communication from the drop-down menu.
- Select the Patient Preferred Linked Organization from the drop-down menu.
- The BHCD Aggregate ID field is used for generating a specific reporting file to a NYS county funding source.
- Enter the specific Bin# bin/storage place where the patient’s medications are kept.
- Check the box for Do Not Schedule Individual Appointments so that individual appointments cannot be scheduled for the patient in question.
- Check the box for Enable Mouth Check to allow staff to conduct a mouth check.
- This can be used when dispensing medications.
- Check the box for Multiple Birth Indicator to indicate that the patient was born at the same time as someone else.
- In the Birth Order field, enter a number to indicate their place amongst their siblings.
- Birth Order field, enter a number to indicate their place amongst their siblings.
Additional Demographic Info (cont.) Tab
- Enter Methadone Central Registry Information.
- Enter Immunizations Registry Information.
- Check the box for Terminal Illness or Patient Deceased if the patient is terminally ill or deceased.
- If so, enter the date of diagnosis or death.
- Check the box for Advance Directive if there is one in place and provide a Reason.
- Restricted Recipient
- Check the box for Patient Restricted if a provider or pharmacy are restricted from the patient.
- Enter the restricted provider and information or pharmacy and information.
- MDOC fields are applicable if your agency is in Michigan and the patient is an inmate with the Department of Corrections.
- Additional forms: Create CCDA, Immunizations, Immunization Query, & CCD are Meaningful Use (MU) specific and can be ignored.
Patient Designation Tab
- For B2H Waiver Type, indicate the B2H Waiver Type if your agency is in the state of New York.
- Check the box for SPMI (Seriously Persistent Mentally Ill) or CSS (Community Services and Support) if applicable.
- For Patient Designation Flags, check any that apply. Doign so will indicate on the banner of the patient chart as a visual cue to staff.
- In the At Risk table, indicate the Start Date of the patient identified as at risk, and elements of the risk strategy: At Risk Category (determining tool), At Risk level, comments, and others as applicable.
- In the Health Home Information table, indicate Name of Health Home, Care Manager/Contact information, Plan ID, Effective Date and if the patient is Enrolled or Engaged.
- In the SED (Seriously Emotionally Disturbed) table, if individual qualifies for SED billing, enter the Start Date and End Date.
- In the Adult BH HCBS Tiers table, indicate the Tier from the drop-down menu, Start Date and End Date of the HCBS services the patient is eligible to receive.
Hospitalizations Tab
- Hospital Discharge
- Enter the Name of Hospital the patient was discharged from.
- From the drop-down menu, select the Type of hospital the patient was discharge from.
- Enter the Hospital Admission Date.
- Enter the Hospital Discharge Date.
- From the drop-down menu, select the Reason for presentation/admission.
- Check the box for Hospital Discharge Papers Scanned if the hospital discharge papers were scanned.
- Select Yes or No from the Was an incident report created? drop-down menu.
- The Modified By field displays who modified the discharge information.
- The Time Stamp field displays when the discharge information was modified.
- Well Care
- Enter the PCP Name (Primary Care Provider).
- Enter the Address of the well care visit.
- Enter the Phone number of the healthcare provider.
- Enter the Fax number for the healthcare provider.
- Enter the NPI of the healthcare provider.
- Select Yes or No from the Have you had a well-care visit within the past year?drop-down menu.
- Enter the Last Wellcare Visit (Month/Year) the patient had.
- The Modified By field displays whomodified the wellcare information.
- The Time Stamp field displays when the wellcare information was modified.
Trainings Tab
Access to the Trainings tab is provided with access to the Additional Demographic Info tab. In this tab, details regarding NARCAN Training are entered for the patient.
Employment/Scholarship Tab
The Employment/Scholarship tab allows you to enter information such as Patient Employment information, Net Available Income and any Scholarship information if that is available.
- In the Patient Employment table, indicate the patient’s employment and employment details.
- In the Net Available Monthly Income table, indicate the patient's net available monthly income.
- In the Scholarship table, indicate the scholarship amount/days provided to the patient.
Payer/SS Fee Tab
Here, you can enter Payer or Subscriber information as well as a Sliding Scale Fee for responsible parties.
- For the Payer/Subscribers information, refer to the Patient Registration article.
- For the Copay for Medicaid, Medicaid Example information, refer to the Sliding Scale Fees training guide.
Authorization Tab
- Authorization subtab
- Enter the Authorization Number provided by the payer or number authorizations entered in a sequential manner.
- Enter the Insurance payer the authorization is linked to.
- Enter the Issuing Provider name who ordered or authorized the services.
- Enter the Authorized Provider name who will deliver the authorized service(s) if required.
- Enter who the authorization was Verified By.
- Enter the Contact Name who provided the authorization.
- Enter the Contact Number and Ext.
- Enter the Contact Fax Number.
- Enter the Contact Email.
- Start Date subtab
- Enter the authorization Start Date and End Date, if required.
- For the Next Review Date, enter a date prior to the end date to obtain new authorization.
- Enter the number of Services / units authorized in both Uses / Uses Left fields.
- The Uses Left number will recalculate as uses are used.
- For Decrement By, based on the authorization, select if it is for services, units or for units based on a specific procedure.
- Additional Options
- Check the box for Inactive to inactivate the authorization.
- Check the box for Prior Authorization if a prior authorization is required before services can be rendered
- Check the box for Do Not Attach to Billing if the authorization information should not to be sent with billing.
- Complete the Diagnosis tab if the authorization is linked to a diagnosis.
- Enter the Authorized Diagnosis.
- Select Inactive to inactivate the diagnosis.
- Completethe Procedures tab if the authorization is linked to a procedure.
- Enter the Authorized Procedure.
- Select Inactive to inactivate the procedure.
- Click Update Authorization List to save the authorization information entered.
- The saved authorization information will display in the Authorizations grid.
- Click Clear for New Authorization to clear the fields to enter a new Authorization.
Service Thresholds Tab
See the Service Thresholds article.
Contacts Tab
- Enter Contact Information.
- Contact information contained in the contact table will be available for selection in various chart forms.
- In the Family Health History table, SNOMED code will show on the diagnosis if one is mapped.
Diagnoses Tab
Diagnosis information will pull from the last completed diagnosis form/document from the patient's chart(s) and populate the Diagnoses tab. This is a read only tab and no edits can be made here.
ePrescribing, Allergies and Medications Tabs
See the ePrescribing articles.
Patient Portal Admin Tab
See the Patient Portal Guide.
Lab Results Tab
Lab Results information will pull from the completed lab results for the patient in the defined date range and populate the Lab Results tab. This is a read-only tab and no edits can be made here.
Lab Orders Tab
Lab Orders information will pull from the completed lab orders for the patient in the defined date range and populate the Lab Orders tab. This is a read-only tab and no edits can be made here.
UDF (User Defined Fields) Tab
The purpose of this tab is to capture any information your organization may utilize that is not currently or commonly found in any standard forms or screens. This section will allow users to add up to 50 customized fields for data gathering.
See the User Defined Fields articles for details.
HIE Tab
HIE (Health Information Exchange) is an additional module available to your agency. Talk to your Project Manager for more information.