Intakes/Notes - Creating new intakes

Ok, you’re ready to chart some notes! You can create a new intake from the schedule by first checking in the patient and then going to the “triangle” to the right of the “Intakes/Notes” button where you’ll see the options to create a “New Intake” or “New Rx”. Creating an intake this way assures that the intake is connected to the “visit,” the place where all the patient charges appear.

The other way to create a new intake is by hitting the “+ Add Intake” button at the top of the “Intakes/Notes” page. You’ll have to manually link the intake to an existing visit or a new one and you do so here.

If you don’t “check in” the patient first, you won’t see an open visit for the day, and importantly, the software won’t be tracking whether or not they showed up for their appointment; hence, we recommend you “check in” your patients and then link intakes to the new “visit” that is created. While you don’t need to link an intake or Rx to a visit, you’ll want to do this if you plan to charge them for services.

Let’s take a look at the intake and how you can customize it. An intake is made up of several “indexes” and these can be “expanded”, “collapsed”, or “hidden” and they can also be moved around on the page. You can also create custom indexes to suit your own needs and all of these settings are in Settings>Intakes>Intake Options.

In Settings>Intakes>Conditions, you can reorder the "conditions" that appear in the "health history" of the patient portal and also in the intake.

There’s a “Simplified intake” at the top if you’d like to freeform write in any notes you desire.

The “Problem List” is the gold standard of an EHR charting procedure, and it’s here where you will give names to your patients health concerns and then write descriptions for each of them. You can designate the intensity of the problem on a scale of 0-10 and also note the date of onset. We help you track which problems are “active”, “inactive”, or “resolved”.

At the bottom of the index, there is a “from history” section where you can “copy here” the problems from the past that you are working on and you’ll see them jump above into your current intake so you may erase and amend the notes. Whatever the patient listed in the patient portal is shown here.

The “Habits & Lifestyle” index has the habits you prefer to ask about and you can customize these in Settings>Intakes>Habits&Lifestyle. Note how you can choose from the list.

Other indexes like “Stools & Urine”, “Sleep”, and “emotions” are there to track these specific categories. Since leaving a field blank has its own meaning, the user can hit the “NAD” button and custom text will be entered into the field.

By default, it says, “nothing abnormal detected” and you can change this in Settings>Intakes>Intake Options.

The “women’s health history” index has a great deal of information to track and you’ll notice that more questions appear as you select “yes”.

The “Review of Systems” index is identical to what is shown in the patient portal, and fully customizable in Settings>Intakes>Conditions where you can deselect these default options and add new ones if you’d like.

You can collect their “Medications and Supplements” info and some other “Western” information and search for ICD-10 codes to give them if you like. Search by code or name of the code, or copy previously used codes “from history”.

Acupuncturists will appreciate Tongue and Pulse options that they can select in the drop down, or by searching through name. Importantly, note that you can also type in whatever you like and entering a comma or hitting the return key will separate the entries.

If you’d like to remove or add various “tongue body colors”, “tongue coats”, or “pulses”, you can do so in the Settings>Intakes pages.

The “Biomedical Diagnoses” can be typed in manually, or you can copy the items from the problem list to get you started, and the “TCM Diagnoses” can also be entered with any text you choose or by selecting one of the drop down entries.

Please note that a “biomedical diagnoses” is mandatory for finalizing an intake.

If you would like to remove or add the available “TCM Diagnoses”, you can do that in the Settings>Intakes>TCM Diagnoses.

If you’re doing acupuncture, then you can add some special text to the “Acupuncture Points” box in the Settings>Intakes>Intake Options to aid your charting.

If you select a “service”, the charge will show up in the “linked visit” which is helpful when checking them out and collecting payment. You can make note of how much time you spent performing various treatments, and even make note of the exact time spent, which can be helpful for charting where your records are evaluated by insurance companies.

AcuBliss makes herbal and supplement prescribing easy. Once you have “activated” the vendors you prescribe, or added your items from inventory, you’ll be able to search for the items and select them. Designate the quantity, dosage and frequency and you’ll see if you have inventory on hand, how long the prescription will last, and the cost (including tax) so that you can inform your patients in front of you.

Give refills that will be tracked over time, and type in some extra notes if you like for the Dymo label. The label is already set up with all of your important information about the prescription.

See the patient’s active prescriptions in the “From history” section and “re-prescribe” them with a click of a button, or “discontinue” them as well. See important metrics like when the item was last prescribed, and when the prescription should be used up.

Want to make a “Custom Rx from Inventory?”

Click the button and then start by determining if the formula is going to be a “granule” one or a “raw custom formula.” After that you can either free-form select the ingredients, one by one with a quantity, or if you are creating a formula based on one of the formulas found in the Materia Medica, you can search for and select the formula from the drop down menu and hit “Base on formula”

This will fill out your formula with all of the ingredients of the base formula and each of the ratios will be shown to the right. Change the dosage, delete ingredients, add new ones. If you don’t have the herb in your inventory, then you will have to search for a replacement. If you’d like to change the total quantity of the formula without changing the ratios, then you can enter in a new quantity into the “proportionate to” field and click the button to adjust the quantities of each herb in the formula.

And if you’d like to combine the formula you just built with a new formula, simply search for and select the new formula and click on “combine with formula” and watch as the new ingredients are added. If a single herb appears in both formulas, you will manually have to determine the dosage.

And before you’re done, you can save the formula as a "specialty formula" you created to offer to other patients if you like.. This could be handy for re-creating “patent formulas.”

The difference between “Custom Rx from inventory” and “Custom Rx to send out” is that the latter is a formula that you will build and then have someone else fill for the patient, such as a pharmacy. Everything is the same, but it’s no longer checking your inventory to see if you have the herb.

Finally, you can add in images to an intake, such as a photo of the patients tongue or a skin lesion that you are treating.

If you’d like to finalize the intake you can do so here and please note that you must save the intake before you put your computer to sleep or shut it down.