It is easiest to navigate to a patient's program page, such as "CCM" by clicking the respective button located under "Programs" in the left hand menu, as shown below.

After searching for a patient in the search bar, click on a patient's name or EHR ID in the list to view their page. You can also search for them in the bar on the right hand side.

The first part of the patient chart a user will see is the patient's Basic Information and Note sections. Here you can see the patients Name, DOB, Gender, EHR ID, and other relevant patient information.

Note: The information presented here can be edited under the 'Patient Info' tab and by clicking the 'Edit Patient' button and modal as shown below.

The next section is the patient "Contact Information" which is displayed in the highlighted box below. This can be viewed by clicking on the "Patient Info" tab. This would come in handy if a user was needing to reference the patients phone number from the CCM Page.

Note: If a phone number, email, or other field was not provided for the patient the field will show as "N/A".

Next, is the patient "Conditions Information" section. To navigate here, click on the "Care Management" tab, and then proceed to a program tab like "CCM".

You'll see the "Conditions Information" section. You can click on "Manage Conditions" to add mode conditions to the list if necessary.

Once the user clicks on "Manage Conditions", an "Edit Patient Conditions" pop-up will appear, an example of the pop-up is shown below. To learn how to add patient conditions click here.

After that, users will come to a small section that lists the patient's Care Team and specific program information.

Users have the ability to edit the Care Team by clicking the provider's or care manager's name.

If a user wishes to begin a new care plan assessment, simply click the "New Care Plan" button located on the right hand side. This can only be done after the latest care plan has been finalized.

Additionally, users can view the progress being made in the patient's monthly workflow.

The next section to the right of "Condition Information" is ThoroughCare's time logger. To learn how to use the time logger click here.

To continue to manage a patient's care plan a user must navigate to the bottom of the program page. Scroll down until the page below is visible.

Problems

The first tab shown automatically will be the patient's "Problems" tab. From here users can view the current conditions associated with the patient and relevant information for each one.

Goals

Next, under the "Goals" tab, users will see the patient answers gathered from the most current care plan assessment.

Note: This will be empty if you have yet to complete a care plan assessment.

Barriers

Next is the "Barriers" tab, where clinicians can add any notable barriers to care for this particular patient. To add a barrier, click on the "+" button on the right.

Once you do so, a pop-up will appear titled "Add Barrier". Here you'll be able to add what the barrier is, its status, and which problem it should be assigned to. Click "Save" to save the barrier.

When a user would like to log an update, click the "Add Update" button located in the text box to the right of the Care Plan section the update is for.

Interventions

In the next tab, "Interventions", the same logic applies. Use the "+" sign to open the pop-up titled" Add Intervention. Here, you can add a specific intervention, its status, and which problem to assign it to.

Select the appropriate tab at the top to classify if this intervention from the care manager, patient, or from a service/program. Click "Save" to save the intervention.

Clinical Review

The next tab is "Clinical Review". This tab provides the user with an overview of all relevant clinical information, including:

The user can include updates for each of these fields as well by clicking on the "Add

Update" button to the right of the relevant field that the user wants to update.

Once you click there, a pop-up titled "Goal Notes" will appear. Include your note and then click "Save" to add it to the clinical review.

Additionally, you can filter these notes by care manager, using the dropdown list on the top right. Select a specific care manager from the list, and only their notes/updates will be shown.

Provider Review

This is where providers can sign off on a care plan, add notes, and review the most recent care plan. The provider can add notes under various fields on the right, as well as sign off on the care plan.

When you click to sign off on the care plan, a pop-up titled "Provider Sign-off" will appear. Select the sign-off date by clicking on the date box (a calendar will appear). Once the date is selected, click "Save" to complete the sign-off.

Patient Vitals

This tab keeps track of any readings that have been made of the patient. The existing readings will appear automatically. You can use the "Enabled Measurements" dropdown list at the bottom of the screen to find a comprehensive list of readings, from which you can select which ones to view.

Click "Details" on any of the panels to view a more in-depth presentation of the readings.

Time Logs

The second to the last tab displayed on a program page is the "Time Logs" tab. Under this tab, users are able to edit and delete time logs.

Note: For more information on how to create time logs and time log reports click here.

If a user wishes to edit a time log, they can simply click the "Edit" button located underneath the "Actions" button.

If a time log needs deleted, a user can delete a time log by clicking the "Delete" button located underneath the "actions" column.

To export the time logs to a PDF, click "Report" on the top right. Your browser will then download the PDF for you to view.

The Time Logs tab will only show the existing time logs for the current month.

Notes

The final tab on the CCM management page contains the "Notes" section. Here care managers can add any additional notes that do not fit in the previously explained sections.

The notes section breaks down into two different sub-sections. The "New Conditions Notes" is the first section that is highlighted below. It contains notes for:

The second section listed is the "Other Notes" section. It contains notes for:

If you wish to add notes to any of these note sections, first, make sure the user name and the date in which the note will be logged from are correct, second, click the "+" button to pull up a note pop-up.

Enter the note within the text box provided.

When the notes is added and the user is finished, click the "Save" button.

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