There are a few different methods of documenting patient care in Mahmee. Here is a breakdown of different options, when, and how to use them.
Appointments
Documenting care during an appointment or meeting (in-person or virtual), should be done in an appointment chart. You may choose to create your own appointment chart with our chart builder feature, or you may use one of the many pre-made appointment charts from Mahmee. A Visit Summary tab is included at the end of each appointment chart. Information documented in the appointment chart is not visible to patients. However, patient can see the Visit Summary. Standard practices recommend documenting patient care in an appointment chart no later than 24 hours after the appointment.
Note: Patients cannot see information in care documentation sections of an Appointment chart. They can only see the information written in the Visit Summary.
Visit Summaries
A visit summary is a patient-facing, post-visit care plan that contains treatment plans, care directives, and support. Patients receive a visit summary after each appointment or interaction with a care provider. This should include clear, specific plans of care for the unique needs of the patient.
Patients access their Visit Summary from their Mahmee dashboard to easily view, print, and show to other care providers. This helps facilitate patient compliance and empowers patients to use as a reference when speaking with their care providers.
Visit Summaries are visible to members of the patient’s Care Team, which prevents providers from giving patients different care directives that may counteract the family's goals. Seeing a patient's entire care plan allows providers to review the information that other providers have given so that supportive advice is communicated clearly. Visit Summaries are found on the patient’s medical record under the ‘Appointments & Interactions’ tab.
Pro Tip: Create and review the visit summary alongside the patient, at the end of the interaction or visit so that important information is retained and the patient has the opportunity to ask questions, playing an active role in their care.
Best practices when creating Visit Summaries.
Create a Visit Summary after each appointment with a patient. If the patient's Care Plan changes during an Interaction or through messaging correspondence, include a Visit Summary.
When possible, write the Visit Summary in conjunction with the patient. This allows the patient to reinforce their understanding of the care plan and ensures you provide answers to their questions. This is done in telehealth appointments and in person appointments.
Be comprehensive. Avoid partial sentences or sentence fragments. Use Mahmee’s Visit Summary prompts to avoid having to write common care instructions for each appointment.
Back up your Visit Summary by attaching an educational article or a clinical treatment plan to the patient's Care Plan - directly from the Visit Summary.
Make it personal. Use the parent’s and baby’s name when writing instructions. For example: Instead of “Feed the baby 8 - 10 times per day,” use “Feed Olivia 8 - 10 times per day.”
Always provide next steps or follow-up plans for the patient. This may involve referring the patient to their care provider or receiving a referral. Include instructions on how to contact you if they have any questions.
Show the patient how to access the Visit Summary. Visit Summaries loose all meaning if a patient cannot access it. Show the patient (on their mobile device or using your screen) where to locate their Visit Summaries from their patient dashboard in Mahmee.
When following up with a patient, review their previous Visit Summaries from appointments. This informs you on what the patient’s plan of care is, and what informational material they received.
Interactions
Use an Interaction to document patient care when an appointment has not occurred or is not necessary. Interactions are short and concise, unlike documenting care in an appointment. Examples of Interactions include:
Short phone conversation with the patient
Phone conversation with a member of the patient's Care Team.
Care coordination notes
Privacy settings are customizable for each Interaction. You may choose to allow the Interaction to be viewable to the patient, or be viewable to other providers on the patient's Care Team.
Upload documents/files
Superbills, correspondence, external documents, images, and files can be attached to a patient's medical record and appointment session. Perhaps a patient needs a letter confirming a diagnosis. Or another care provider has sent you a report. These documents should be uploaded into the patient's medical record. What if a patient requests a superbill for a specific date of service? Since this is an appointment specific file, upload this into the appointment's session.
