Step-by-Step Guide to using the Cognitive Assessment Work flow | Scribe

Step-by-Step Guide to using the Cognitive Assessment Work flow

    1
    Open a FNC Liberty Doctors note and enter vitals as you would normally. BMI an BP will auto calculate codes when entered and add those codes under the SP tab. Next click on the CC Tab.
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    Click on Health Maintenance
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    Choose the Congitive Assessment under Symptom
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    Nest Go to the Assessment Tab
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    Click "New" to add new assessments for this patient.
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    There are 3 specific Assessments for the Cognitive Assessment. 1. NPI, 2. CRD and 3. FAST. You may also want to add Patient Health Questionnaire PHQ2/PHQ9 and the STEADI Falls Risk if needed. Not shown here.
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    Fill out each assessment and score each. If additional Assessments are to be added Click "New" to add additional.
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    Adding additional Assessments example, the NPI was added, now adding the CDR.
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    Fill out each questionnaire as you are adding them and scoring appropriately at the bottom of each Assessment (scores will be added to the HPI in later steps. Writing down each score may be helpful when entering scores in the HPI. You can also go back to the assessment tab to review score if needed. Note also that forms **do not AUTO Score**. Scores must be entered manually.
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    Once all Assessments have been added and scored, click on the HPI Tab.
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    Choose the Cognitive impairment planning to drop the applicable billing code 99483 to the SP section of the chart.
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    Choose Answers to question under "Visit Type".
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    Move on to the "Patient History obtained" section and select appropriate answer.
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    Move to the "Patient History/records reviewed". Yes and No (specify)\_ allows you to enter additional information as needed. The actual review of the patient history should be preformed under the HX tab. Addressed in later slides.
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    Continue moving down each section and answering questions for ADL's IADLs Staging of Dementia testing etc... Each category can be addressed as needed in any order needed by clicking on the category to the left.
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    For "ADL's" the top selection is for Independent, if they are not, insure you click the Patient is not independent, as well as the items they are not independent in.
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    Example, patient is not independent in all ADL, and requires assistance with Dressing...
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    Do the Same for "IADLs"
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    If you did the FAST Assessment with the patient, choose preformed, then enter the score you entered on that Assessment below the "preformed" choice.
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    Example of entering the score you entered on the Assessment Form.