Continued Care: Completing an Individual Session

Individual sessions provide a structured, private setting where case managers, therapists, and providers assess patient progress, address challenges, and tailor treatment plans. Sessions typically last 45–60 minutes and occur using telehealth or in person, depending on the patient’s level of care. Follow the steps below to complete an individual session effectively.

Required Permissions: Users with the Therapist, Case Manager, Super Admin, or Records Admin role added to the user profile. 

Best Practice Workflow Video

Best Practice Workflow Steps 

Let's review Kipu EMR's best practice workflows to complete an individual session.

Workflow 1: Telehealth Individual Session Using Zoom

1. Navigate to Scheduler and select List View. You can also use the Workflow View or Calendar View.
   
2. Click on Individual Session in the Appointment Subject column.
3. Click the appointment status icon and select Check-In to indicate that the patient is present in Zoom on the Scheduler appointment card.
   
4. Click on Start Meeting.
5. The clinician conducts the telehealth session on Zoom. Click here to learn more about telehealth benefits.
6. Click on Documents to add the progress note linked to the appointment card.
• Note: If the progress note is not linked to the appointment card, use centralized documentation to add the progress note to the patient chart.
  
7. Check the patient out once the telehealth session is over.
8. If necessary, add an appointment in Scheduler. The patient will receive a reminder depending on the configuration.

Best Practices: Kipu’s pre-population feature streamlines documentation but requires accurate timing and backend settings to ensure proper data flow. Use the copy evaluation button to duplicate progress notes for continuity. When a progress note template is updated, create a new note using centralized documentation and apply copy evaluation to future entries. Favorite frequently used documents for quick access. Super admins must notify users of template updates.

Workflow 2: In-Person Individual Session

1. Resolve any flags upon patient arrival and collect lab specimens, copays, or integrated assessments for higher levels of care.
2. Navigate to Scheduler and select the List View. You can also use the Workflow View or Calendar View.
3. Click on Individual Session appointment subject.
4. Click the appointment status icon and mark the patient as checked in on the Scheduler appointment card.
5. Click on Documents to add the progress note linked to the appointment card.
6. Document all progress including patient statements, clinical or medical updates, and diagnosis code changes (if applicable).
   
   • Best Practice: Standardize diagnosis code entry by using the Manage Diagnosis Code evaluation form instead of embedding codes in individual documents.
7. Sign the documentation using your PIN.
   
8. A physician or nurse practitioner updates medications as needed.
9. Complete any additional documentation, such as Treatment Plan updates, Outcome Measurements, or Integrated Assessments.
   
   • Note: If patient's signature is required, you can submit the document via the Patient Portal. Go to the appointment card and set the patient status to Ready for Check-Out.
10. If sessions do not recur, add an appointment in Scheduler.
    
    • Important: If a different user schedules the follow-up appointment, the Ready for Check-Out step is unnecessary. Mark the appointment status as Checked Out.
11. The patient receives configured reminders for their next scheduled appointment.
    

Best Practice: Configure a Scheduler appointment type for each session (e.g., Nutrition, Therapy, Case Management, Physician, Nurse) to link specific documentation to the appointment card. If multiple provider types require different progress notes, create distinct appointment types to ensure proper documentation. Kipu’s pre-population feature streamlines documentation but requires precise timing, accuracy, and backend settings to ensure proper data flow into evaluations. Use the Copy Evaluation button to duplicate progress notes for continuity and favorite frequently used documents in Centralized Documentation for quick access. 

By following this structured workflow, providers, therapists, and case managers can efficiently conduct, document, and schedule Individual Sessions while maintaining compliance and continuity of care.

• Zoom-HIPAA-Compliance-Datasheet.pdf 200 KB