Clinical Add-Ons Section

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This section supports practices that use any of the following service type add-ons:

  • CHDP Confidential Screening Billing Report PM 160 (California only)
  • Chlamydia Reporting
  • Title X Family Planning
  • UDS Reporting

 

This section appears in the Intake checklist (above the Quality Measures section) and in the Review step of the Exam stage of the encounter. This section is also accessible on the Billing tab during the encounter Sign-off stage.

 

 

 

Your practice must use the Service Type Add-ons feature and must have at least one service type add-on configured for the patient department. You must have access to the patient encounter.

 

 

 

  1. Display the Intake page of an encounter, and click Clinical Add-Ons in the visit checklist.
  2. Click the plus icon to open the Clinical Add-Ons section.
  3. In the Clinical Add-Ons box, check the box next to a service type add-on to display the details.
  4. Review and update the appropriate fields and click Save.

Note: Some information contained in the service type add-on is derived from data previously recorded during the encounter and can be updated by changing the associated encounter field. Information displayed as "No data currently available" is recorded at a later point in the encounter.

  1. Click outside the Clinical Add-Ons box to close it.
    The service type add-on is added for this patient, and the Clinical Add-Ons section displays information about the update.

 

  1. Display the Review page in the Exam stage of an encounter.
  2. Click the plus icon to open the Clinical Add-Ons section, where you can select a service type add-on, review add-on information, and save the add-on for the patient.

 

 

 

If your practice has the CHDP PM160 service type add-on enabled, a checkbox for CHDP PM160 appears in this section. Check the checkbox for CHDP PM160 to record encounter data that is included on the confidential Screening/Billing Report (PM 160).

 

Some fields display clinical data entered in other encounter sections. You can edit this information in the encounter section where the data was entered.

 

The data appears on the Billing tab in the Sign-off stage, under the heading Clinical Add-Ons, and in the service type add-on fields at charge entry. At Charge Entry, when you click Save & Enter Charges to create a claim, the selected service type add-ons also appear on the claim.

 

 

Type of visit Editable within encounter. Select New patient or extended visit or Routine visit.
Type of screen Editable within encounter. Select Initial or Periodic.
Birth weight Editable within encounter. Enter weight in lbs. and oz.
Height Read-only within encounter. Determined by what is documented in the Vitals section of the encounter.
Weight Read-only within encounter. Determined by what is documented in the Vitals section of the encounter.
BMI Read-only within encounter. Determined by what is documented in the Vitals section of the encounter.
Blood pressure Read-only within encounter. Determined by what is documented in the Vitals section of the encounter.
Head circumference Read-only within encounter. Determined by what is documented in the Vitals section of the encounter.
Hematocrit Read-only within encounter. Determined by the latest Hematrocrit lab result value.
Hemoglobin Read-only within encounter. Determined by the latest Hemoglobin lab result value.
Second-hand tobacco smoke exposure Read-only within encounter. Determined by what is documented in the Social History section of the encounter in the Passive smoke exposure field.
Tobacco use

Read-only within encounter. Determined by what is documented in the Social History section of the encounter in the Tobacco smoking status fields.
Counseled regarding smoking prevention/cessation? Editable within encounter. Select Yes or No.
History and physical exam Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Dental assessment/referral Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Nutritional assessment Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Anticipatory guidance health education Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Developmental assessment Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Snellen or equivalent (visual acuity) Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Audiometric Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Hemoglobin or Hematocrit Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Urine dipstick Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Complete urinalysis Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
TB mantoux Editable within encounter. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.
Other tests

Editable within encounter. Add other tests not already documented within the form. Select Problem Suspected, No problem suspected, or Refused / contraindicated / not needed. If you select Problem Suspected, select up to two items for each: New problems, Existing problems.

Diagnoses Read-only within encounter. Determined by what is documented in the Assessment / Plan section of the encounter. The first three diagnoses are auto-populated.
Routine referrals Editable within encounter. Select Blood lead and/or Dental.
Referrals Read-only within encounter. Determined by what is documented in the Assessment / Plan section of the encounter (specifically, the first two referrals ordered in this section).
Immunizations Editable within encounter. Indicate the immunizations and the status of each immunization.
Comments / problems Editable within encounter. Enter any notes to include on the PM160 form.

 

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