Nurse's Progress Note (Short)

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Nurse's Progress Note (Long)

While the long and short notes were primarily designed for nurses working within a practice that provides psychiatric medication management, there are many other instances where using these templates would be appropriate. The BH - Nursing Note template (long note) should be used when it is apparent that there has been a significant change in the client's status. The long version of the template enables the documentation of vital signs and other medication concerns that may need to be conveyed to the psychiatric prescriber. Both versions of the nursing note are available from the navigation bar. Enter the Program Name Record Vital Signs for the Nurse Progress Note Document Individuals Present Enter an Interim Update Record New Issues Update the Client's Current Assessment Record a Risk Assessment Document Medication Information Enter Patient Allergy Data Enter Goals, Objectives and Interventions Addressed Today Enter Plan of Care and Additional Information Enter Assessment and Diagnosis

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BH - Contact Note Template

Use the BH - Contact Note template to document billable treatment contacts with the client. This includes goal sessions with Personalized Recovery Oriented Services (PROS), case management, residential programs, and Permanent Housing Programs (PHP). The BH - Contact Note template may be used, for example, by a case manager reviewing an Individualized Recovery Plan (IRP) with a client. This information connects to the standard objectives and interventions to assist in the overall care of the Behavioral Health client. These billable encounters must include the staff’s interventions and/or services provided and the individual’s response to those interventions. Visit Types for the BH - Contact Note Enter the Program Name Document Individuals Present Record New Issues Enter Goals/Objectives and Interventions Addressed Today Enter Assessment and Diagnosis Details Sign the Behavioral Health Document Finalize Behavioral Health Billing Parent topic: Individual Visit Workflows for Behavioral Hea

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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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BH - Individual Counsel/Psych Prog Note Template

The BH - Individual Counsel/Psych Prog Note template enables you to document individual counseling services and the client's progress or the lack thereof. Any risk assessment, goals, objectives, or assessment data that was entered previously on the Comprehensive Assessment template set populates in the panels found on the Progress Note tab. You can document new issues and make updates to the goals, objectives and interventions. Use the Behavioral health billing section to submit billable service codes to the Superbill. The Progress Note tab can be a stand-alone template or used in conjunction with the other tabs or links. Enter Program Name Record Individuals Present Update the Client's Current Assessment Record a Risk Assessment Record New Issues Enter Goals, Objectives and Interventions Addressed Today Document Plan and Additional Information Enter Assessment and Diagnosis Details Sign the Behavioral Health Document Complete Behavioral Health Billing Parent topic: Individual Visit Wo

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Screening and Admission Visit Workflow

The BH - Screening/Admission Note template is used to document information that a program or Emergency Room might need for their initial evaluation of a client. Information gathered here is the basis for a summarization of the services and possible interventions that are initially provided to the client. Generally, this is completed by the non-clinical staff at the practice and can be done separately from a Comprehensive Assessment exam. The BH - Screening/Admission Note template can be accessed at any time during an encounter by selecting Other Templates from the bottom section of the navigation bar. Document Admission Data Document Referral Source Enter Assessment and Diagnosis Details Add Additional Notes Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Behavioral Health

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Sign the Behavioral Health Document

Multiple people can sign the Behavioral Health document utilizing the Signature panel. Security on the Signatures panel is set up so that only the person who checks a signature line can alter it in any way. The client and/or parent/guardian’s signatures can be captured with electronic signature software. To document your signature in the Signatures panel, place a check mark next to the appropriate label. The current user’s name fills the Name field and the current date populates the date of the signature. Enter your Credentials. Select N/A to indicate that a signature is not applicable and to clear the fields of anything that may have been entered in the same row. Click the Send Task button to forward the template to the next person who needs to record their signature. If your signature does not fall under the preset options, enter your Name and Credentials in the Additional Staff section. Enter Comments as needed. Click Add. The signature details appear in the grid. Parent topic: BH -

Nurse's Progress Note (Short)

Recommendations

Nurse's Progress Note (Long)

BH - Contact Note Template

BH - Psychopharm Template

BH - Individual Counsel/Psych Prog Note Template

Screening and Admission Visit Workflow

Sign the Behavioral Health Document