You should schedule a follow up session when you plan to meet with a patient individually to follow up on the patient’s progress from the previously scheduled session. Follow up sessions are scheduled as new one on one sessions.

Before the Session

Connect and Coach enables you to prepare for patient educational sessions by completing some tasks in advance of the appointment. Before a session, you should create the session in Connect and Coach so it is ready when you want to begin documenting patient information. You should also review any data you entered during or after your last one on one session with the patient.

Chapter 1. Create a New One on One Session

In preparation for a follow up session with your patient, you should create a new one on one session.

Remember that if you are assigned to multiple sites within your program, you should confirm that you are viewing the correct site before adding a new class. Classes are added to the site you are currently viewing; the name of the site you are viewing appears in the bottom right corner of your Connect and Coach screen. If you need to switch sites, click on the site name.

Switch Sites

The Switch Sites screen opens.

Switch Sites

Click the name of the site you wish to view.

Once you have confirmed that you are viewing the correct site, you are ready to create a follow up session. First, you must select the appropriate patient.

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Select Patient
  1. Click the Patients tab.
  2. To locate a patient, you can search by First Name and/or Last Name. The smart search will populate all records with matching information until you narrow down the search to your patient.
  3. Click on Select to access the assessment form options for your patient.

After clicking Select the assessment choices appear for the patient:

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Choose Assessment
  1. Choose the Assessment you wish to complete
  2. Choose the Subsession (aka reason code)
  3. Click on Begin New Assessment with Selected Patient

Your second option for creating a new one on one session is to do so through the Education/Assessments tab:

education assessments circle

When creating a new one on one session, you have the option to create a basic one on one session, or to create a one on one session from a template. A follow up session will typically be scheduled as basic one on one session.

1) Create a Basic One on One Session

Create Basic One on One

Create Basic 1:1
  1. Click the Create Basic 1:1 link.

The Create New 1:1 Session screen opens. Required fields are underscored.

Create New One on One Session Screen Updated
Create a New 1:1 Session
  1. Choose a name for the session and type it in the Class Name field. For example, you might choose to call a follow up session “Follow Up”. The class name can be anything that makes sense in context; however, it should not contain the patient’s name. The class name defaults to Basic 1:1.
  2. Enter the Session Date.
  3. Enter the Session Time.
  4. The Attendance drop-down list allows you to specify whether the patient attended the class. Because the class has not yet occurred, you will want to change this field to appropriately reflect the patient’s attendance status after the class, if it differs from what you enter today.
  5. From the Assessment Form drop-down list allows you to specify which form to associate with this class. The form you specify will be used to document the patient interaction after the session.
  6. If any portion of the session is billable, you will specify the billable subsession in the Billable Portion section. Select the Subsession Name from the drop-down list. Select the number of units from the No. of Units drop-down list. Click Add.
  7. If any portion of the session is non-billable, you will specify the non-billable subsession in the Non-Billable Portion section. Select the Subsession Name from the drop-down list. Select the Time from the drop-down list. Click Add.
  8. Enter any relevant notes in the Session Note field.
  9. Click Save Changes.
The one on one session you have just created now appears in the Class List as shown below.

 

New One on One Class Created

Chapter 2. Review Patient Data

Prior to your follow up session with your patient, you should review the information contained in the Patient Information screen to familiarize yourself with the data you collected during the last session.  For some assessments, the answers from previous assessments will display on future assessments as a popover next to the question.

First, you must select the patient you wish to review. Once you have located the patient whose data you wish to review, click the patient in the list. Doing so opens the patient’s information; patient information defaults to the General Information screen.

By clicking the tabs in the Patient Information section on the left side of your screen, you can review information you entered during your last session. Sections available for review include:

Patient Information
  • General Information
  • Insurance, Referrals, Billing
  • Client History
  • Food History
  • Biochemical Data
  • Comparative Standards
  • Diagnosis/Intervention
  • Medications
  • Contact History
  • Education/Assessments
  • Notes
  • Documents

During the Session

Connect and Coach offers several options for documenting information during a follow up counseling session.

Chapter 3. Note Taking

Connect and Coach features a notepad you can use to make notes during patient interactions. To access the notepad, click the Notepad link shown below.

Notepad Link

The Notepad opens on the right side of your screen.

Notepad
Notes
  1. Notes that you enter on the notepad are saved automatically; you can navigate away from the notepad and come back to it at any time without loss of data.  Notes will carry over from assessment to assessment so it is advisable to date your notes.
  2. You are able to print your notes by clicking Print.
  3. You are able to hide your notes by clicking Hide.
Best practices for use of the notepad feature include:
  • Use the notepad to temporarily capture patient information.
  • Review the notepad after the session and document the information in the appropriate location. Connect and Coach supports the copy and paste shortcuts.
  • If you have a template of questions to ask during the session, paste it into the notepad for use during the session.

Chapter 4. Start New Assessment

Connect and Coach allows you to document a variety of patient assessments during a counseling session. To start a new assessment:

Start New Assessment

 

Start New Assessment
  1. From the list of scheduled patient education activities, locate the class or session for which you want to document a patient assessment.
  2. Click the link in the Assessment Form section. The name of the assessment will vary based upon which assessment form you specified when you created the class. In this example, the link is Begin Individual (other common forms are Initial Assessment or Follow-up Assessment).

Patient Assessment forms in Connect and Coach feature four key areas that enable you to navigate the assessment process easily and efficiently.

Patient Assessment Screen

Patient Assessment Form
  1. At the top of the screen, you have the option to Save and Close the assessment, access the Notepad, or Print the assessment.
  2. Next, you find a summary of patient demographic information such as name, age, height, weight, hemoglobin level, and blood pressure.
  3. The Assessment Status drop-down list allows you to specify whether an assessment is Incomplete, In-Progress, or Complete.
  4. A navigation panel resides on the left side of your screen. This box shows which section of the patient assessment you are currently viewing, and allows you to navigate to other sections with a single click of the mouse.
  5. Enter patient assessment values on the right side of the screen. Data saves automatically while the assessment screen is open. When you finish entering patient assessment values, click Save and Close to return to the patient information screen.

Section 1. Documenting Barriers

While conducting a patient assessment, it is likely that you will identify some barriers to learning and/or challenges to a patient’s ability to adhere to a self-management plan. Documenting these barriers will enable you to follow up on them and monitor a patient’s progress in overcoming them.

Document Barriers

Documenting Barriers
  1. Locate the Identified Barriers to Learning/Adherence to Self-Management Plan section of the Education/Assessment screen.
  2. Click New Entry.

The Edit Identified Barriers screen opens.

Edit Barriers
Documenting Barriers
  1. From the drop-down box, specify when the barrier was identified.
  2. Enter a description of the barrier you identified.
  3. Click Save Changes.

Chapter 5. Entering Patient Data

Connect and Coach features a robust Electronic Health Record that allows you to document a wide variety of patient data.

By clicking the tabs in the Patient Information section on the left side of your screen, you can navigate between data categories:

Patient Information
  • General Information
  • Insurance, Referrals, Billing
  • Client History
  • Food History
  • Biochemical Data
  • Comparative Standards
  • Diagnosis/Intervention
  • Medications
  • Contact History
  • Education/Assessments
  • Notes
  • Documents

After the Session

The process for generating a Snapshot Report to provide information to a patient’s Primary Care Provider is covered fully in the Snapshot Reports for Referrers of Patients topic. The process for Preparing and Sending a Bill for the session is covered fully in the Prepare and Print HCFA 1500 topic.