EHR Preconfigured Section 2 - Problems List, Encounter Diagnoses, and Billing


The Problem List, Encounter Diagnoses, and Billing Sections are preconfigured within MacPractice. Preconfigured section cannot be changed within MacPractice.

The Problem List section will save all entries in the database to be seen on the patient's Clinical Summary. The Problem list is also visible in the Clinical tab, this allow reports to search for patient's with specific problems.

The Problem List section can be setup to show just ehe active Problems or the entire history of Problems for the patient.

Check the Problem Verified every time the Problems are confirmed to be correct on the patient's chart.

If the patient does not have any active Problems, check the box to notate this on the patient's chart.

If a Problem was identified by another office, click the reconcile button and select Add New List for Reconciliation. Identify the origin of the Problem List. If the list was sent from a referral, use the popup box to select an existing referral or select a referral from the database. 

Click the Problems link to add the known Problem into the patient's chart. Use the hierarchy of folders to search for a diagnosis. If you know the name of the diagnosis, you can search using the box at the top of the sheet. The Patient tab will show all the diagnosis codes that have ever been used on this patient's account. The favorites tab will show the diagnosis codes that have been marked as a favorite code. To mark a code as favorite, double click the start to activate. The top 50 tab will show the top 50 codes used in the office for all patients.

MacPractice is also equipped with an ICD-9 Helper. Activating the helper will allow you to search through the known ICD-9 codes. Once an ICD-9 code has been selected, MacPractice will show related ICD-10 codes.

Once a code has been added to the patient form, select the name of the Problem to add additional details. If the item is regularly treated, check the box to place this code in the encounter diagnosis section.

Continue to add problems in this window until all known problems have been added.

Click the next button once all the problems have been added. MacPractice will display which problems are already on file and which problems have been added during this transition of care. Uncheck a problem box if there are two duplicate problem records.

Click the next button to see a final preview of the problems on the patient's on the patient's record. Click next to finalize the problem list reconciliation.

If a patient's problem is no longer active, click the name of the problem and change the Status popup to inactive or resolved. This will remove the problem from the active list but keep the record on the patient's account.

It is best practice to use the Encounter Diagnosis section if a new Problem is identified during the patient visit at your office.

The Encounter Diagnoses section is broken into two parts. The Current Encounter Diagnoses , and Past Diagnoses and Problems. The Current Encounter Diagnoses codes will be used for billing within MacPractice. 

Click the Encounter Diagnosis link to enter the new problem. Enter details by clicking on the name of the problem in the patient's form. If a problem should be added into the ongoing problem list, click the button or the link to add to the Problem List.

Past Diagnosis and Problems will display all the codes that have been marked as Regularly Treated in the Problem list. Click the upward arrow if Past Diagnosis from the current Encounter Diagnosis but will not remove it from the patient's Problem List.

The Billing section is used as an electronic care-slip or superbill within MacPractice. Click the Charges link to search for the procedures that were performed during the visit. You can search by description or code number.

MacPractice will automatically assign the Current Encounter Diagnosis codes to the procedure. If the details need to be changed, click the procedure and update the relevant information. Diagnosis codes can be reordered in the following screen.

Once all the Charges have been entered, click the Create Billing Order link. MacPractice will save the patient form and create a billing careslip in the orders tab of the patient chart. 

Visit the HelpDesk to learn more about posting Careslips in the patients Ledger.

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