Quick Reference — To complete transition of care documentation during the encounter

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You can mark an encounter as a transition of care encounter in the Reason for Visit step of the Intake checklist or in the Review step of the Exam stage. The best practice is for an MA, nurse, or other staff to mark the encounter as a transition of care encounter during the Intake stage.

Note: For more information, see Transition of care documents and the Medicaid PI HIE measure on the Summary of Care Record/Continuity of Care Document page.

 

Before you begin the Exam stage, review the Quality tab, which displays HIE Receive and Incorporate measure details for encounters marked as transition of care. "Needs data" indicates that you must discuss the electronic summaries related to transition of care with the patient during the exam. athenaOne removes the measure from the tab after you satisfy the measure.

  1. To begin the Exam stage, click Go to Exam in the upper right corner of the screen.
    The Newly referred patient or a patient being referred back option appears in the Reason for Visit section.
  2. Confirm with the patient that this encounter is a transition of care. If the Newly referred patient or a patient being referred back option is not selected, select it now.
    Note: If the encounter is not a transition of care, deselect the Newly referred patient or a patient being referred back option if this option is selected.
  3. Scroll down to Documents for Discussion.
    Electronic summaries related to the transition of care are listed.

    Note: Documents labeled "Summary of care," "Continuity of care," "Referral note," or "Discharge summary" satisfy the HIE: Receive and Incorporate measure. Any other documents related to a transition of care that appear in the Documents for Discussion section do not satisfy the measure.

If transition of care documents are available

  1. Discuss each summary of care document with the patient.
  2. Check the box next to each document after you review it, or check the Discussed all box.

If transition of care documents are not available

  1. If no transition of care documents are available for this encounter, specify whether you requested the document from the provider.
  2. Electronic summary wasn't found. Have you requested it? — Select an option.
    • Click Yes if you contacted the organization that the patient is coming from to request the summaries in CCDA format. The encounter is excluded from the HIE measure.
      Note: Keep the encounter open until you receive the transition of care documents. Return to the encounter and select YES when you receive the documents.
    • Click No if you will not contact the organization that the patient is coming from to request a transition of care summary. The HIE measure is counted as unmet for this encounter.

After you complete the Exam stage, "Transition of Care Encounter" appears in the encounter summary and the full encounter summary.