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Forms - Care Slips and Encounter Forms

A Care Slip reference is a set of codes that can be printed on a patient's encounter form or placed in an EMR/EDR form for the purposes of identifying the applicable diagnoses and procedure codes for the patient's visit.

An Encounter Form usually contains a care slip, and can be used to recount the details of a patient appointment. An Encounter Form may also be referred to as a routing slip or a superbill. All of these items fulfill the same function, and are set up using the Care Slip Reference of MacPractice.
 
After updating to the latest version of MacPractice 5, the Care Slip codes will need to be updated to the coding system as defined in the Coding Preference. See Updating a Care Slip for more information.

Enabling the Care Slip/Encounter Form
To first create a care slip/encounter form it may be necessary to activate the form in MacPractice. To do this, navigate to the Reference ability, select the Forms node in the sidebar, and click the disclosure triangle to reveal the list of forms.

 
Select a Care Slip or Encounter form and check Form Active checkbox. After activating the form, be sure to save the changes by going up to the Edit menu and choosing Save Record, or using the Command-S keyboard shortcut.
 
Creating a Care Slip Reference
In the References ability, select the Care Slip node in the sidebar and click the plus button in the upper right corner to create a new record. After creating the new record, select the Care Slip Name field, and enter a name for the newly created care slip.


Next, configure the care slip options:
  • Form: Select from the active care slip forms.
  • Fee Schedule: Select the fee schedule to pull fees from; only one Fee Schedule can be chosen.
  • Maximum Pages: This field sets the maximum number of pages the care slip will print.
  • Test: Use the Test button to see the care slip as it will appear when used with a patient.
  • Form Active: This will allow the form to be active and selectable.
  • Print Letterhead: The Print Letterhead option will only function with select forms.
Procedures Tab
Procedure codes can be added by clicking the plus button to open up the fee schedule window, which will display all fees in the selected fee schedule. After selecting the desired fees, click the OK button to add the fees to the care slip. After adding the fees, be sure to save the changes in the Edit menu by choosing Save Record, or by using the Command-S keyboard shortcut.
 
Searching for a code with existing codes selected will replace the selected codes. The Insert Space button will insert a space between procedure codes.

Diagnoses Tab
Diagnosis codes can be added by clicking the green plus in the right corner. This will bring up a list of Diagnosis codes based on the coding preference established in Preferences > Coding > Problems. This view is slightly different than other diagnosis coding views in MacPractice, as it is possible to select multiple codes at once by holding down the Command key.
 
Searching for a code with existing codes selected will replace the selected codes.
 
The Update Coding Preference button will designate the Code Type if it is blank. If this type is left blank, it will lead to future problems when utilizing the EMR Care Slip element. When the button is clicked MacPractice will display a prompt to save changes before continuing.
 
A second alert will appear, asking to duplicate the care slip before updating the codes. It is recommended to duplicate before updating.
 
If MacPractice is able to identify a one-to-one match with the code type currently set under Preferences > Coding, this will be done automatically (after either duplicating the care slip reference or updating the code). If it is not possible to identify a one-to-one replacement, these codes will need to be updated manually by adding a new code.

Having a code present in the Care Slip without a Code Type can lead to inaccurate diagnosis codes being displayed in the Care Slip element of EMR, or those codes not reflecting what is currently checked in the patient's Problem List because the code types do not match. Disparities here can lead to duplicate codes being added to the patient's Problem List.
Note: This does NOT map your Diagnosis Codes.
 
The Insert Space button will insert a space between Diagnosis Codes.
 
Setting the Default Care Slip/Encounter Form
After a care slip/encounter form has been created or activated it is ready to be used. The default care slip/encounter form can be selected in Preferences > Forms > Default Encounter Form area. When the Default Encounter Form menu is selected, all encounter forms and care slips that have been enabled or created will be displayed. After selecting a form, exit out of the Preferences window to save the defaulted form.


Updating the Care Slip
After updating to the latest version of MacPractice 5, the Care Slip codes will need to be updated to the coding system set in the Coding Preference. First, set the Coding Preference to the desired code system. Next, click the "Update to Coding Preference" button on the Care Slip in References > Care Slip within the Diagnoses tab. This will update all billable codes going forward.

If both custom codes and ICD-9 codes are used in the Care Slip, update the Custom codes before the ICD-9 codes. Set the Coding Preference to Custom, then click the Update Care Slip to Coding Preference button on the Care Slip. Repeat the Care Slip update process after switching the Coding Preference to ICD-9.
 
Currently only billable diagnosis codes can be added to Care Slips. After updating the Care Slip, non-billable codes will appear as blank codes in the code type column. While these codes can still be used, once they are removed from the Care Slip they cannot be added again.
 
Print a Care Slip/Encounter Form
There are several different ways to print a Care Slip/Encounter Form:
  • To print a single care slip from the Patient ability, go to the patient's ledger and select the Print menu, then choose Print Encounter Form. When the print dialog window opens, select Print.
  • To print a single care slip from the Schedule ability, drag the patient's appointment from under the Appointments node to the form listed under the Forms node in the sidebar. When the print dialog window opens, select Print.
  • To print out all care slips for all patients that have appointments on a particular day, go to that day on the Schedule. Drag the Appointment node in the sidebar onto the Care Slip under the Forms node. When the print dialog window opens, select Print.
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