Patient Interactions

Once you have added your patients to the Connect and Coach platform, you are ready to begin counseling. Connect and Coach enables you to schedule and document patient counseling interactions in a variety of settings, including one on one sessions, follow up sessions, and group classes. While the documentation process for each type of class is similar, there are some differences in the way the each are set up in Connect and Coach.

Individual 1:1 Classes

You should create a one on one class when you plan to meet with a patient individually to discuss history, habits, goals, etc.

Chapter 1. Before the first Session

Connect and Coach enables you to prepare for patient counseling sessions by completing some tasks in advance of the appointment. Before a session, you should create the class in Connect and Coach so it is ready when you want to begin documenting patient information.  You can do this in one of two ways.  1.) You can choose the appropriate assessment form from the patient Search page or 2.) you can create an assessment through the Education/Assessments tab.   Prior to the appointment, you should also review any pre-assessment (PSA) data present in the patient’s record. The PSA data will also appear as a popover in the assessment forms.

Section 1. Create a New One on One Class

In preparation for meeting with a patient for the first time, you should create a new one on one class for that patient.

If you are assigned to multiple sites within your program, confirm that you are viewing the correct site before adding a new class or session. 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 Window. 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 new one on one session. Your first option is to create the one on one assessment using the shortcut from the Search page.  First, you need to select a 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:

 

assessment-selection

Choose Assessment
  1. Choose the Assessment you wish to complete (examples include Initial, Follow-up and Biometric Screening)
  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

You have the option to Create Basic 1:1 session, or to Create 1:1 From Template. First, we will discuss the process for creating a Basic 1:1 session.

1) Create a Basic 1:1 Session

Basic1_1

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

The Create New Class screen opens. Required fields are outlined in red.

Create New Class_updated

Create a New Class
  1. The navigation defaults to the Class Information tab.
  2. Choose a name for the class and type it in the Class Name field. For example, you might choose to name the class “Initial Visit”. The class name can be anything that makes sense in context.

Create New Class_Session tab_updated

 

Create a New Class
  1. Click on the Session Information tab
  2. Enter the Session Name. If it is the same as the Class Name you can simply click on Copy class name.
  3. Enter the correct Session Date.  It defaults to today’s date.
  4. Choose an Assessment Form from the drop down list. The form you specify will be used to document the patient interaction during the session.
  5. Choose a Start Time.
  6. You will specify the subsession (also know as reason code) in the Billable Portion or Non-billable Portion depending on whether or not you will bill insurance for the session.  Select the Subsession Name from the drop-down list.
  7. Select the number of units from the No. of Units or Time drop-down list.
  8. Click Add. Note: At least one Subsession Name and Time is required in order to advance.  You must click the green Add button in order for it to accept.
  9. Click Save Changes.
The one on one class you have just created now appears within the Education/Assessments tab as shown below.   The Initial Assessment you assigned to this class is a live link to the assessment.  You can access all assessments in this view should you need to revisit a completed assessment.

Initial Assessment

2) Create a 1:1 Session from a Template

create from template

Create 1:1 From Template
  1. Select a template from the Create 1:1 drop-down list.
  2. Click Create 1:1 From Template.

The Create Class from Template screen opens. The top half of the screen is the Class Information section.  The Required Fields are circled in red.

class from template

 

Class Information
  1. Edit Class Name if appropriate.  It pre-populates with the name of the template.
  2. Edit Closed after session field
  3. Choose an increment for the class in the Repeat field.  Choices are does not repeat, daily, weekly, bi-weekly and monthly.
  4. Edit Start Date and Start Time.  Field will default to today’s date

The bottom half of the Create Class from Template screen is the Class Sessions section.

bottom class from template

Class Sessions
  1. Session Name, Date, Start time and Assessment Form all pre-populate.
  2. Enter any relevant Class Notes.
  3. Save Changes

The one on one class you have just created from a template now appears in the Class List as shown below in the Education/Assessments tab.
saved tamplate class

Section 2. Review Patient Pre-Assessment Survey Data (PSA)

When you added your patients to Connect and Coach, you had the option to send them a welcome e-mail with a link to a pre-assessment survey. Prior to your one on one class with the patient, you should review the information contained in the Pre-Assessment Survey (PSA) to familiarize yourself with any information the patient may have provided in advance of their appointment.

You can access a pdf file of the customer’s PSA answers by navigating to the Education/Assessments tab.  Under the Customer Survey section you will see a link to PSA Answers. When you click on this link the pdf file will load and you can view the file.

PSA Answers

 

Review PSA Answers
  1. Click the Education/Assessments tab.
  2. Click on PSA Answers link
  3. Open pdf file containing customer’s PSA answers

Chapter 2. Online Assessment Forms

Connect and Coach allows you to collect patient data during your counseling session by utilizing online assessments.  These assessments streamline the data entry into the overall electronic health record for your patient.  Typically, the assessment forms are called Initial and Follow-up.  They are also referred to as Detailed Assessment or Simplified Assessment, depending on your program.

Section 1. Initial Assessment

The Initial Assessment is the most comprehensive assessment form.  Its purpose is to guide you through the data you would like to collect during a counseling session.  This data then populates into the broader tabs within the patient’s electronic health record.  Online assessments prevent you from having to “hunt and peck” during a session to find where you should enter patient data.

Sample Initial Assessment Form:

Chelsea screenshot

Section 2. Follow-up Assessment Form

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The follow-up assessment form is an abbreviated version of the initial assessment focusing on the data points you would likely collect in a follow-up visit.

Sample Follow-up Form:

Follow-up-screenshot_updated

 

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. The Assessment Status drop-down list allows you to specify whether an assessment is Incomplete, In-Progress, or Complete.
  3. 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.
  4. Enter patient assessment values on the right side of the screen. Data saves automatically when you advance to a new page in the assessment.  If you need to leave your computer in the middle of the page you must hit Save/Calculate in order to save your data otherwise it will be lost when the system times out after 10 minutes of being idle.  (This is a HIPAA feature)
  5. When you finish entering patient assessment values, click Save and Close to return to the patient’s record.

Section 3. Notepad

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.  NOTE:  The notepad is meant to replace paper and pencil notes you might take while in a session.  It is not meant for documenting clinical data. The Notepad is also different than a clinical Session Note which can be documented in the online assessment or via the Education/Assessments tab in the patient’s broader electronic health record.

Notepad link

 The Notepad opens on the right side of your screen.

Notepad screenshot_updated

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 carry over from session to session.  It is advisable to date your notes so you can differentiate them easily.
  2. You are able to print your notes by clicking Print.
  3. You are able to hide your notes by clicking Hide.

Section 4. 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:

 

tabs

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

Chapter 3. After the Class

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 section. The process for Preparing and Sending a Bill for the session is covered fully in the Prepare and Print CMS-1500 section.