You can document counseling details, educational materials provided or used, or interpreter details for a client on the Counseling Details (BH) template. Multiple people in the practice can make entries on this template.
- From the Evaluation and Management Coding panel on the Finalize (BH) template, select the Counseling Details link.
The Counseling Details (BH) template opens.
- In the Counseling/Education Details section, enter the following for each counseling item:
- Type of counseling
- Method of counseling
- Evaluation of counseling
- Time
The name of the logged-in user fills the Counselor field. Today’s date fills the Date field.
- Enter the number of minutes spent on the counseling item.
- Enter Comments.
Note: For billing and documentation purposes, the steps described above are the only required fields.
- Enter Educational materials provided or used.
Documenting patient education here does not count for Quality Reporting.
- To indicate that an interpreter was used, select the Interpreter used checkbox and enter the following:
- Language
- Interpreter’s name
- Relationship
- Interpretation Involvement
- In the Counseling/Education Factors section, select the Detailed document or Reviewed option.
- Enter Readiness to learn, Barriers to learning, and Learning preferences.
- In the Cultural/Spiritual needs section, select No or Yes, then enter details in the corresponding field.
Previously documented information appears for Marital status, Race, and Religion.
- Select Save & Close.
