Standing Orders can be created via a Multiscale Questionnaire & added to any procedure. They can also be easily referenced in subsequent procedures until the document expiration date. Follow the steps below to create a Standing Orders template, add it to a procedure, and reference your Standing Orders in a procedure.
Creating the Multiscale Provider Questionnaire
1. Head to the Settings wheel to get started.
2. Navigate to Clinical Documentation
3. Click Client Paperwork
4. Select Multiscale Questionnaires then Create Questionnaire
5. Name your exam something obvious for your Providers to locate. In our case, e are calling it Good Faith Exam and Standing Orders
To start adding questions, click Add New Question
6. You can leverage the variety of question types we have available in the Multiscale Questionnaires. For multiple select, choose Multiple Choice.
Below is an example of the Chief Complaint question.
7. Based on your scope of practice and your state regulations, add the appropriate questions to your Standing Orders. Below, we've included toxin, filler, energy devices, vitamins and peptides all in one exam. You could break these up into multiple exams or make them as detailed as you need based on your regulations.
8. For instance, you can simply choose the areas of approved treatment for neurotoxin, or if your state requires a specific dosage, you can either free type that in a text box as a follow up question or you can create an individual question per indication using the Text Box option.
9. You can organize services as we did with filler and toxin by indication or you can group several things together that do not require specific dosages as we've done below with an overall "Vitamin and Peptide" category.
10. We recommend adding a confirmation question for the Provider to acknowledge they've reviewed any intake questionnaires and to be able to provide feedback accordingly.
Considerations When Creating Services
11. If you prefer to create a specific appointment type for GFEs for better chart categorization, you can follow your normal procedure for creating the service.
12. Be sure to only add providers who can perform a GFE.
13. This is where the process will differ- you will NOT INCLUDE your new Standing Orders questionnaire in the service. If it is attached here, it will go out to the patient when the procedure is booked, and we only want the provider to have access to it during the procedure.
Completing Your Standing Orders Questionnaire During a Visit
14. Once you are in the appointment where you will perform the GFE or create the Standing Orders, you will add the Standing Orders questionnaire when you are creating the procedure.
If that is in a Cosmetic procedure, you will add it during the questionnaire step. If it is a Health procedure, you will add it as shown below- on the Select Questionnaires line. In the Health procedure case, you will click Save & Fill Questionnaire to complete the orders.
15. Prior to completing your Standard Orders, you can click into the other questionnaires to review those responses. When you are ready, click Fill to complete the questionnaire.
16. Here are some of the examples of our questions: Chief Complaint
17. Notice on the Yes / No questions, you will have a text box to add additional information.
18. As a reminder, you can do a more generic version and just add the areas of indication as you see below or you can break these out into individual questions with a text box for specific dosage.
19. Once you complete your Standing Orders, you will see it turn green for Filled.
Locating Prior Standing Orders
20. If you are the ones who needs to reference the Standing Orders in preparation for treatment, you can always find the prior completed questionnaires under Documents. From the web or app, navigate to the Document Repository.
21. Find the Standing Orders questionnaire, and you can open it up by clicking on the document icon.
22. Based on your state, you will likely have expiration requirements for your Good Faith Exams and Standing Orders. Those timelines can be set from Settings > Clinical Documentation > Document Expiration. If the document is out of compliance, it will have a red stop watch, otherwise it is still active.
23. You can also change the expiration date directly from the Document Repository by clicking on the stopwatch and changing it in the popup menu.
Referencing Standing Orders in a Procedure
Tip: To complete the following procedure note example, you will want to create a dot phrase that can be used to signal that Standing Orders / GFE were done by the appropriate provider prior to the procedure. See below for an example.
24. When you are ready to chart your procedure notes, you can reference the existing Standing Orders for documentation purposes. Head to View Notes on a Cosmetic procedure or you can add it directly into the Encounter Note or add as a Procedure Note on a health procedure.
25. Click into the NOTE section.
26. We've already created a Dot Phrase we can add by location .GFEonfile which includes information about our prior GFE and Standing Orders.
27. Select it, and your dot phrase will appear. In our case, it has the name of our Medical Director on it, and an * to indicate where the provider needs to add the date of the original exam.
28. To complete the note, the provider can type in the date the Standing Orders were created (available in the Document Repository and on the questionnaire)
29. If you are using ChartSmart to document (way to save time!), you can add your dot phrase into any chart during the editing phrase, or if you add it in your original dictation, it will be saved as part of the fully formatted chart note.
30. You will see it saved in formatted text once you complete any ChartSmart edits and click Save.
That's all you need! As a reminder, to get started:
Build your Provider-facing, Standing Orders Multiscale Questionnaire
Create a dedicated service, if you prefer, to make it easy to find your GFE/Standing Orders procedure on the timeline (and use your chart categorization so it's easy to search)
Create a Dot Phrase that references a prior GFE or Standing Orders so that you can add that information to any procedure that where delegation is required.