BH Hx Section Tab Overview

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BH - Psychiatric Evaluation

The Psychiatry Eval tab is designed to be a stand-alone template for a psychiatrist, nurse practitioner (NPP), or other Behavioral Health professional who is qualified to conduct and document an initial psychiatric assessment of the client. The information on the Psychiatry Eval tab overlaps with the data recorded on the Comp Assess tab. Of the 17 panels on the tab, only two (Physical Health History and Issues for Children/Adolescents) are not identical to the corresponding panels on the Comprehensive Assessment. If a Comprehensive Assessment was completed for this client prior to the Psychiatric Evaluation, much of the information is filled. It is important to note that medications can be prescribed during the psychiatric evaluation. The Behavioral health billing section is available at the bottom of the Psychiatry Eval and Progress Note tabs to submit billing codes. Some providers may want to use the SOAP tab to document additional elements of the physical exam. For more information

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BH - Brief Assessment Template

The BH- Brief Assessment template enables providers, case workers and social workers, to document on an abridged version of the Comprehensive Assessment template set. Because a comprehensive exam takes a significant amount of time (more than a single client visit), the BH - Brief Assessment template can be used to complete the evaluation during one encounter. Start a New Intake for a Brief Assessment Record the Client's Presenting Concerns Brief Assess Histories Panel Record Substance Use and Addictive Behavior Histories Enter Tobacco Usage Add Trauma History on the Brief Assess Record Mental Status Exam Information Record a Risk Assessment Enter Assessment and Diagnosis Details Enter Treatment Plan Information Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Intake Visits for Behavioral Health

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BH - Psychopharm Template

The BH - Psychopharm template is intended for the Behavioral Health prescriber to document a follow-up visit. The interventions can be tied to the client's treatment plan, but the content is specific to the needs of psychiatric professionals who prescribe medication. Access the BH - Psychopharm Template Enter Program Information Record Vital Signs for the Nurse Progress Note Document Individuals Present Record Mental Status Exam Information Enter the Prescriber's Evaluation Record a Risk Assessment Document Medication Information Enter Assessment and Diagnosis Details Enter Goals, Objectives, and Interventions Addressed Today Record Plan Details Enter Document Signatures Parent topic: Behavioral Health Medication Management

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Social Hx of a Comprehensive Assessment

The Social Hx section tab enables you to continue with the Comprehensive Assessment and document the client's living situation, development history, social supports and more. Maintain Family Data for the Client Document the Client's Living Situation Enter Developmental History Information Document Sexual Issues Enter Social Supports Record the Client's Legal Issues Enter Education History for an Adult Client Enter Education Information for a Child/Adolescent Document the Client's Employment Status Document Military Service Maintain a Record of the Client's Trauma History Parent topic: Comprehensive Assessment Template Set

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Access the BH CA Presenting Concerns Template

To complete a comprehensive assessment as part of the intake process, enter the following information on the Home Page - Behavioral Health template: In the Visit Type field, select a value from the picklist. Select Intake no Medical Services or any of the other Visit Types listed in the above section of this User Guide. Click the Comp Assess tab to launch the BH CA Presenting Concerns template. The Concerns section tab is highlighted to indicate that you are on the w template. The abbreviations presented in the name of the template refer to Behavioral Health (BH) and Comprehensive Assessment (CA). Parent topic: Comprehensive Assessment Template Set

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Substance Use Assessment Exam

BH Substance Use Assessment is a template on which a clinician or nurse can gather information about a client’s substance use history and how an addiction might negatively impact the client’s life. The information gathered on this template is configured to appear on whatever document is generated. It is one of just a few templates that launches with all but the top panel collapsed. This was done to make it easier find and use the appropriate panel. The recommended workflow is to expand a panel to document the information and collapse it when that section is complete. This template is launched from a Substance use link found on the Substance Use/Addictive Behavior panel. This link is also available on many templates throughout the Behavioral Health template set. Enter Chemical Use/Abuse History Add Substance Use Data Document Tobacco Use on the Substance Use Assessment Exam Add Gambling Information Document Impact of Substance Use/Addictive Behaviors of Life Areas Enter Toxicology Scree

BH Hx Section Tab Overview

Recommendations

BH - Psychiatric Evaluation

BH - Brief Assessment Template

BH - Psychopharm Template

Social Hx of a Comprehensive Assessment

Access the BH CA Presenting Concerns Template

Substance Use Assessment Exam

BH - Psychiatric Evaluation

BH - Brief Assessment Template

BH - Psychopharm Template

Social Hx of a Comprehensive Assessment

Access the BH CA Presenting Concerns Template

Substance Use Assessment Exam