The Current Assessment panel provides quick entry of whether there has been a change or no change in the client’s condition. There are buttons to indicate the client’s progress or lack of progress.
Navigate to the Current Assessment panel and select one of the statuses for Individual’s progress.
Complete the Individual’s report of progress towards goals/objective since last session field.
Enter No significant change or Notable change and if notable is selected, list the changes in individual’s condition field for the following:
Mood/affect
Thought process/orientation
Motor activity and speech
Behavior/functioning
Medical condition
Substance use/addictive behaviors
If there has been any change in these areas, enter information about the change into the respective field or select Not applicable.
To complete a full Substance Assessment, click on the Substance Use link to launch the BH Substance Use Assessment template.
To document a comprehensive exam for the client’s current mental status, click Mental Status Exam.
Note: Information from previously documented Mental Status exam does not copy forward onto future encounters.
