Primary Care Note

Primary Care Note

Primary Care Note
 
A Security Administrator can request to have the Primary Care Note enabled by emailing ticket@icanotes.com. For primary care providers who will be utilizing auto coding for e/m coding, please refer to this knowledge base article. 
 
 
Creating a Primary Care Note
 

1.  Click the Primary Care button at the bottom of the patient's Chart Face.
 
 
 

2.  Throughout the program, buttons are organized in a clinically logical format. Begin your button selection by moving from top to bottom in the left gray column. Start by clicking the Chief Complaint button and typing the patient's chief complaint after the populated text. 
 
   
 
 

3.  Click the  button to document history of risk factors, current risk factors, protective factors, and other suicide/violence related factors, as needed. Simply click on a shrub to expand further options to the right. Once you're finished, click  in the upper-left or lower-right to navigate back to the main Primary Care Note window. 
 
 
 

4.  Click the  button to chart your physical exam with the patient. 
 
 
 

5.  If a patient has no other complaints, you may click one of the 'ALL NORMAL' shrubs and then edit the populated text in the yellow field accordingly. 
 
 
 

6.  You can use the other shrubs to add more specific information or create the physical exam from scratch. The example below shows shrubs that were sequentially clicked to indicate that:
  1. There is a neurological abnormality  
  2. The abnormality is related to tremors
  3. All cranial nerves were checked

 
 

7.  You can document OBGYN and Prostate Exams in Primary Care Notes by clicking  and  respectively. 
 
 

8.  Click the  button and enter all of the screenings that are appropriate for the facility, regulatory agency, insurance payer, etc.
 
 
 

9.  Click the  button and enter rating scales, as needed. The example below shows the PHQ-9 rating scale with a score of 7. 
 
 
 

10.  Click the  button to add adverse drug reactions and/or allergies for the patient. For more information, please see our New Allergy/Adverse Drug Reaction Entry Workflow knowledge base article. The adverse drug reaction (ADR) & allergy list window looks like this:
 
 
 

11.  Click the  button to add new immunizations or observe existing immunizations that have been received. 
 
 
 

12.  Click the  button to do a detailed Review of Systems.
 
 
 

13.  Click the  button to record vital signs. Fill in the fields by using the dropdown menu choices. When done recording the vital signs, click the  button. 
 
 
 

14.  ICANotes will automatically calculate the patient's BMI. If the patient's BMI is considered under/overweight, the following dialog will appear: 
 
 
 

Click  to enter instructions and recommendations. For example, you can indicate that you referred the patient to a dietitian and addressed barriers to change. 
 
 
 

15.  Click the  button to address tobacco use. The tobacco use window looks like this:
 
 
 

16.  Click the  button to enter lab results, as needed. The test results window looks like this:
 
 
 

17. Click the   button to access the Clinical Order Sheet and access lab and other clinical orders. 
 
 
 

18. Click the   button if you will be utilizing auto coding for determining the highest reimbursable service code. For more information on e/m auto coding, please refer to this knowledge base article.  
 
 
 

19. Click  to access the Mental Status Exam, including Physical Exam, AIMS, Constitutional/Vital Signs and Musculoskeletal. 
 
 
 

Starting with Appearance, then Speech and Language, Mood, etc, you can use the included clinical content to build the text of the mental status exam.  Use the Normal MSE button where needed to help write the note. 
 
 
 

Below the yellow text areas you can click to additionally access the Physical Exam, AIMS, Constitutional/Vital Signs, and Musculoskeletal exams. You may also include custom buttons to the right of the MSE work area. 
 

To return to the main work area of the Primary Care note, click Back. 
 
 
20.  Click the  button above the service code box to enter the service code(s). 
 
 

Select the service code(s) and modifier(s) from the dropdowns and enter the billing rate(s). 
 
 
 

21.  Click the  button above the Diagnosis box to enter the diagnosis code(s). For more information, please see our How to Enter an ICD10 Diagnosis knowledge base article.
 
 
 

22.  Enter length of session, start/end time, managed care authorizations and units, as needed.
 
 
 
23.  Click the  button in the lower-right to save the Primary Care Note to the chart. The compiled Primary Care Note looks like this:
 
 
 
24.  Click the  button to sign and lock the note. 
 
 
 
With multiple medical disciplines working together to provide integrated care for patients, we know the importance of coordination between general and behavioral healthcare. At ICANotes, this includes integrating mental health, substance abuse, and primary care. Join our Chief Clinical Officer, October Boyles, for a brief demonstration of the new ICANotes Primary Care Note. Throughout the 9-minute video, October will create a Primary Care note while highlighting the features available for use by primary care physicians. 
 


 
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