Precompleted progress note for Face To Face encounters

Face To Face documentation is required for Medicare/Medicaid patients needing Home Health Services. It is mandated by the Affordable Care Act and is a condition for payment. In order to facilitate documenting the encounter, a Precompleted Progress Note containing repetitive information can be set up in the Physician’s Care Connection Notes. This document contains instructions for creating and accessing that template.

Access the progress note

  1. Access Care Connection and select a patient record.
  2. Select Physician Progress Note – Add from the menu.
  3. Click the Tab named Encounter Pathway and type Home in the search field. Documents with the name Home in them display.

  1. Select the Home Health Face to Face- AHC document. (Note: If you order home oxygen, a template must be established for that as well.
  2. Click the Structure hyperlink. The Face to Face template appears.

Set the Precompleted Progress Note Defaults

  1. The Face to Face Encounter Date and Diagnosis (entered in the Clinical Reason for Home Care field) must be entered for each patient.
  2. In the Type of Service field, click Skilled Nursing to set the default. Select other options as needed.
  3. In the Home Care Intervention field, click Skilled nursing assessment and click medication management to set default options. Select other options as needed.
  4. In the Homebound Patient field, click Requires max assist to leave home to set the default. Due to (post op weakness, CHF exacerbation, debility…) Select other reasons as needed. There must be 2 homebound qualifiers.
  5. In the Outpatient Managing Physician field, click Provider and enter you name in the dialog box to default to your name. In the Certification field, click Statement to set the certifying statement as the default.
    “I certify that at the time of this Face To Face encounter, the patient was under my care and that I have initiated the plan of care for Home Health Services for the reasons stated above.”

To Save the Precompleted Template

  1. On the Menu Bar at the top of the screen, select Documentation/Save as Precompleted Note. ..

The Note Title defaults to the name of the document you selected.

  1. Click Save as New.

WARNING : After creating a “Precompleted” template click “Cancel” in bottom right hand corner. Then click “discard changes” so nothing is saved to the current patients chart.

To access any “Precompleted” note, select the Precompleted tab in Physician PowerNote +ADD.

To quickly find your note: You may want to restrict display to “My notes only” .

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