Select a note or plan type from the Documentation menu, New or Open. All notes and treatment plan reports open in a Session Information window with fields for recording the date, provider, and program. Use your tab key to move from field to field.
Date
To enter the date, type in the field, or click the down arrow to select a date from the calendar. For Discharge notes enter the discharge date.
Provider
You can select a provider, if different from the patient's primary provider. Click the down arrow in the Provider field for a list.
Program
The Program field is used to filter reports and graphs, as well as to filter the session list in the Note Hx tab in QuicDoc's main screen. Select one from the drop down pick list. If you type a program name in the field that is not on the list, you will be prompted to save it to the program list.
Other Fields for Session Information are determined by the note or treatment plan type you open.
Intake and Progress Notes
Session Length
Enter the start and end times (Intake and Progress Notes) using the hh:mm a/p format. For example, for 10:00 am type 10a. The Length field, in minutes, is automatically calculated for you. Session length is used in the Contact Hours Report.
CPT Codes for Service
CPT Codes are used in tracking Authorizations. Sessions are listed in the Apply Sessions window for Authorizations, and they are listed with dates and CPT codes in the patient's Note Hx tab of the Patient window. In order for CPT codes to be listed, they have to be entered in the Session Information window.
In the Session Information window, click the button to the right of the Service field to open the pick list, or tab to the filed and press the Enter key to open the list.
Select the code, and click the Select button.
To add CPT codes to the pick list, click the Add/Edit button.
Progress Notes: When you select a CPT code for Group Psychotherapy, additional fields become visible for entering the Group Name, Co-Leader, and the number of people present. These fields are only available for Progress Notes when selecting a Group Psychotherapy code.
You can setup a Default CPT in the Client Setup.
Type of Visit
Click an option for either scheduled or emergency to record the session type.
Legal status of Patient - Intake
Click an option to select the legal status and, if applicable, record any pending charges.
Others Present
Record the names of others who were present in the session.
Schedule Appointment
Click the calendar icon in the upper right of the window to schedule a next appointment for a client while in the Session Information window for Intake and Progress Notes.
Apply session to an Authorization
If you have entered an authorization for the client, click the blue underlined text 'Click Here to Apply Session to Authorization' to apply the session.
Discharge Note-Session Information
Select an option for the Discharge Status and the Discharge Condition.
Select a Reason for Discharge from the pick list, or you may type in the filed. For Total Sessions Seen, select an option either Total Sessions or Hospital Days, and then click the Calculate button. You can override the number by simply typing it in the field.
Note: If you have entered a prior patient or client, add the number of previous sessions or hospital days to the calculated number for the total number of sessions or days.
Click the button for Discharge Recommendations. Click the down arrow for a pick list. Select a recommendation, and then click the OK button to add it to the list. Or you can type in the field.
If you have access rights, you can click the pick list icon to edit the list.
Discharge Summary
Click the tab button to enter a Discharge Summary. To spell check select File...Spell Check.
This is an ideal area to use a voice recognition program.. You can also copy and paste text from another document by using the Edit menu in the document's application. Open or switch to the application where the document is located (e.g. MS Word). Select Edit...Select All or mark a section of document to copy. Select Edit...Copy. Switch to the Plan screen in QuicDoc and click in the text box. Press Ctrl-V to paste, or right-click and select paste.
Treatment Plans - Session Information
Legal status - Inpatient
Click an option to select the legal status and, if applicable, record any pending charges.
Track Treatment Plans
Click the blue underlined text Click Here for Treatment Plan Tracking in the Session Information section to mark scheduled plans as completed and to schedule the next plan.
Mark a scheduled plan complete and schedule the next plan. Click Done to mark a plan completed.
To schedule a new plan, click the down arrow for a calendar to select the Date. Click down arrow for a pick list to select a priority rating, and enter an optional note.
Click Save to save and close.
Help and Tips
Context Sensitive Help is available from every screen.
| • |  Click on the help icon in the upper right of the screen, or press F1. |
| • | Select Help Topics from the Help menu. |
| • | Screen tips or instructions are located on most screens. |
| • | Context sensitive instructions for entering information in the fields is displayed as you move from field to field. |