Skip to main content

Patient Management

Complete guide to patient intake, demographics, and record management

Overview​

The Patient Management module is your central hub for all patient-related information including:

  • Demographics and contact information
  • Insurance coverage details
  • Emergency contacts
  • Clinical history
  • Document management

Adding a New Patient​

Step-by-Step Process​

1. Navigate to Patient Intake

  • Click "Patient Intake" in the sidebar
  • Or go to Dashboard → "Add New Patient" quick action

2. Complete Demographics Tab

Required fields (marked with *):

  • First Name *
  • Last Name *
  • Date of Birth *
  • Gender *
  • Phone Number *
  • Address (Street, City, State, ZIP) *

Optional but recommended:

  • Email address
  • Preferred contact method
  • Language preference
  • Race/ethnicity (for reporting purposes)
  • Emergency contact information

3. Add Insurance Information

Primary Insurance:

  • Insurance Company *
  • Member ID *
  • Group Number
  • Policy Holder Name
  • Policy Holder DOB
  • Policy Holder Relationship

Secondary Insurance (if applicable):

  • Same fields as primary
  • Automatically checked for COB (Coordination of Benefits)

Tips:

  • Use insurance card scanner if available (Phase 2)
  • Verify active coverage before first session
  • Update when insurance changes

4. Save Patient Record

  • Click "Save Patient" button
  • System assigns unique Medical Record Number (MRN)
  • Patient now appears in system-wide search

Editing Patient Information​

Quick Edit​

  1. Search for patient (search bar in top navigation)
  2. Click patient name to open record
  3. Click "Edit" button (top right)
  4. Modify fields as needed
  5. Click "Save Changes"

Bulk Updates​

(Admin only)

For updating multiple patients:

  • Export patient list to CSV
  • Make changes in spreadsheet
  • Import updated CSV
  • System validates and shows conflicts
  • Approve changes

Search Methods​

By Name:

  • Type: "Smith, John" or "John Smith"
  • Partial matches work: "Smi" finds "Smith"

By Date of Birth:

  • Format: MM/DD/YYYY
  • Example: "03/15/1985"

By MRN (Medical Record Number):

  • Unique identifier assigned by system
  • Example: "MRN-00123"

Advanced Search:

  • Click filter icon in Patient Intake
  • Filter by:
    • Insurance company
    • Provider
    • Date range (created/last seen)
    • Active vs. inactive status

Patient Record Details​

Tabs Overview​

Demographics Tab:

  • Basic information
  • Contact details
  • Address
  • Emergency contacts

Insurance Tab:

  • Primary insurance
  • Secondary insurance
  • Coverage history
  • Eligibility check results

Clinical Tab:

  • Active diagnoses
  • Current medications
  • Allergies
  • Medical history
  • Treatment plans

Sessions Tab:

  • All appointments (past and future)
  • Session notes
  • Treatment progress
  • Authorization status

Claims Tab:

  • All claims for this patient
  • Payment history
  • Outstanding balances
  • Prior authorizations

Documents Tab:

  • Uploaded documents
  • Consent forms
  • Treatment plans
  • Assessment results
  • Insurance cards

Insurance Management​

Eligibility Verification​

Automatic Check:

  • System checks eligibility when insurance is added
  • Real-time query via FHIR to payer systems
  • Results cached for 24 hours

Manual Check:

  • Click "Verify Eligibility" button in Insurance tab
  • System queries payer
  • Results show:
    • Active coverage (Yes/No)
    • Copay amount
    • Deductible status
    • Behavioral health benefits
    • Prior auth requirements

What to Do if Ineligible:

  • Update insurance information
  • Contact patient to confirm coverage
  • Collect payment information if no coverage

Coverage Coordination​

Primary vs. Secondary:

  • System automatically handles COB (Coordination of Benefits)
  • Primary insurance billed first
  • Secondary billed after primary payment
  • Patient responsibility calculated automatically

Medicare + Secondary:

  • Medicare as primary
  • Secondary insurance (if any)
  • Medigap policies supported

Document Management [WIP]​

Uploading Documents​

1. Go to Documents Tab

  • Click patient record → "Documents" tab

2. Click "Upload Document"

3. Select Document Type:

  • Insurance card
  • Consent form
  • Treatment plan
  • Assessment results
  • External records
  • Other

4. Upload File:

  • Drag and drop, or click to browse
  • Supported formats: PDF, JPG, PNG, DOC/DOCX
  • Max size: 10 MB per file

5. Add Description:

  • Brief note about document
  • Date of document (if different from upload date)

6. Save

Viewing Documents​

  • Click document name to view
  • Opens in browser or downloads
  • Can print directly from viewer

Organizing Documents​

By Type:

  • Filter dropdown shows document types
  • Quick access to insurance cards, consent forms, etc.

By Date:

  • Chronological list (newest first)
  • Can sort ascending/descending

Patient Privacy & Consent​

Required consents:

  • Treatment consent
  • Privacy notice acknowledgment
  • Financial responsibility
  • Release of information (ROI)

42 CFR Part 2 (SUD Treatment):

  • Enhanced consent for disclosure
  • Specific purpose required
  • Expiration date must be set
  • Can be revoked at any time

Managing Consents​

1. Go to Documents Tab 2. Filter by "Consent Forms" 3. Upload signed consents 4. Track expiration dates 5. Renew expired consents

⚠️ Important: Consent Requirements

Standard HIPAA: General consent for treatment, payment, and operations is sufficient for most disclosures.42 CFR Part 2 (SUD): Requires specific, written consent for EACH disclosure with:
  • Name of person/organization disclosing
  • Name of person/organization receiving
  • Patient name
  • Purpose of disclosure
  • How much information to disclose
  • Expiration date or event
  • Patient signature and date

Violating 42 CFR Part 2 carries federal criminal penalties.

Patient Status Management​

Active vs. Inactive​

Active Patients:

  • Currently receiving treatment
  • Appear in normal patient lists
  • Can schedule appointments
  • Claims can be submitted

Inactive Patients:

  • Discharged or left practice
  • Hidden from normal lists (but searchable)
  • Cannot schedule new appointments
  • Historical data preserved

Marking Patient Inactive​

(Admin or Doctor)

  1. Open patient record
  2. Click "More Actions" → "Mark Inactive"
  3. Enter reason for discharge
  4. Enter effective date
  5. Confirm

Effect:

  • Patient removed from active lists
  • Cannot schedule future appointments
  • All historical data preserved
  • Can be reactivated if patient returns

Reactivating Patient​

(Admin only)

  1. Search for patient (check "Include Inactive")
  2. Open patient record
  3. Click "Reactivate Patient"
  4. Confirm
  5. Patient returns to active status

Authorization Tracking​

Viewing Authorization Status​

In Patient Record:

  • Go to "Sessions" tab
  • View "Authorization Status" section

Shows:

  • Sessions authorized: X
  • Sessions used: Y
  • Sessions remaining: X - Y
  • Authorization expiration date
  • Authorization number

Color-coded alerts:

  • 🟢 Green: Plenty of sessions remaining (> 3)
  • 🟡 Yellow: Running low (1-3 remaining)
  • 🔴 Red: Exhausted or expired

Starting Reauthorization​

When to Start:

  • Yellow alert (1-3 sessions remaining)
  • 2-3 weeks before expiration
  • When patient needs more sessions than authorized

How to Request:

  1. Click "Request Reauthorization" in Sessions tab
  2. System pre-fills form with:
    • Clinical progress notes
    • Current diagnosis
    • Recommended sessions
    • Provider information
  3. Review and edit
  4. Submit via PAS (electronic) or print/fax

Data Privacy​

Who Can Access What​

Doctors:

  • Full access to their assigned patients
  • Limited access to other providers' patients (demographics only)

Billers:

  • Demographics and insurance for all patients
  • Limited clinical info (diagnosis, session dates, no detailed notes)

Admins:

  • Full access to all patients
  • User activity logs
  • Audit reports

42 CFR Part 2 Records​

If patient is flagged as SUD treatment:

  • Enhanced access controls apply
  • Requires specific consent for each disclosure
  • Even admins need proper authorization
  • Separate audit trail maintained

Best Practices​

Data Quality​

✅ DO:

  • Verify all information with patient
  • Update insurance before each session
  • Keep emergency contacts current
  • Document consent properly
  • Use standard formats (phone: xxx-xxx-xxxx)

❌ DON'T:

  • Enter dummy data to bypass validation
  • Skip insurance verification
  • Forget to update changed information
  • Share patient records via insecure channels

Organization Tips​

Use consistent naming:

  • Last Name, First Name format
  • Full dates (MM/DD/YYYY)
  • Complete addresses

Regular maintenance:

  • Monthly: Review inactive patients
  • Quarterly: Update insurance on file
  • Annually: Renew consents
  • As needed: Remove duplicate records

Documentation:

  • Upload insurance cards at intake
  • Scan signed consent forms
  • Keep assessment results on file
  • Document phone calls and communications

Common Issues & Solutions​

Can't Find Patient​

Try:

  • Search by DOB instead of name
  • Check "Include Inactive" filter
  • Search partial name (e.g., last name only)
  • Verify spelling (check with patient)

If still not found:

  • Patient may be in different clinic database (if multi-location practice)
  • May have been deleted (admin can check audit logs)

Insurance Not Verifying​

Common causes:

  • Incorrect member ID
  • Insurance not in system yet (add to Payers table)
  • Payer system down temporarily
  • Insurance actually inactive

Solutions:

  • Verify member ID with patient's insurance card
  • Try manual entry if auto-verify fails
  • Contact insurance company directly
  • Document attempt in patient notes

Duplicate Patient Records​

Prevention:

  • Always search before creating new patient
  • Check by name AND date of birth
  • System warns if potential duplicate found

If duplicates exist:

  • Contact admin to merge records
  • Admin can transfer data between records
  • Choose which record to keep
  • Audit trail preserves history

Reporting​

Available Reports​

(Biller and Admin)

Patient Demographics Report:

  • All active patients with contact info
  • Export as CSV
  • Filter by provider, insurance, etc.

Insurance Report:

  • Coverage by payer
  • Expiring authorizations
  • Verification status

Utilization Report:

  • Sessions per patient
  • Authorization usage
  • No-show rates

Running Reports​

  1. Go to Patient Intake or Dashboard
  2. Click "Reports" button
  3. Select report type
  4. Set filters and date range
  5. Click "Generate"
  6. Export as CSV or PDF

Integration with Other Modules​

Scheduling​

  • Patient list auto-populates appointment booking
  • Patient demographics shown in appointment details
  • Insurance info displayed when scheduling
  • CRD automatically checks prior auth requirements

Clinical Documentation​

  • Patient demographics auto-fill session notes
  • Diagnoses carried forward from previous sessions
  • Treatment plans accessible during documentation
  • Risk assessments tracked over time

Billing & Claims​

  • Insurance info auto-populates claims
  • Demographics pre-filled on CMS-1500
  • Authorization status checked before submission
  • Claim history visible in patient record

FAQ​

Q: Can patients access their own records?
A: Phase 2 will include patient portal. Currently, patients must request records from clinic administrator per HIPAA right of access.

Q: How do I share records with another provider?
A: Use FHIR export or generate PDF summary. Always verify patient consent for disclosure.

Q: Can I import patients from another EHR?
A: Yes. Admin can import via CSV upload or FHIR Bundle. See Admin Guide for details.

Q: How long are patient records kept?
A: Per state requirements (typically 7-10 years for adults, longer for minors). System supports archival without deletion.

Q: What if patient wants records deleted?
A: HIPAA doesn't require deletion (archival is acceptable). Discuss with clinic administrator and legal counsel.

Next Steps​

Last updated: November 2025