Record Mental Status Exam Information
- For a more comprehensive record than is offered on the Mental Status Evaluation panel, click the Mental Status Exam link.
The BH - Mental Status Exam template opens.
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The BH - Mental Status Exam template is part of the assessment process (Comprehensive Assessment and Psychiatric Evaluation). The provider’s observations of behavior and assessments of mental health symptoms can be documented here. The Mental Status exam can be completed at every visit and do not copy forward onto future encounters. In the Mental Status Evaluation panel, click the Mental Status Exam link. The BH - Mental Status Exam template appears. The General Observations panel includes the option to select Generally normal for all of the areas presented. You can select this option and still choose specific items under each area to indicate traits observed for this client. If appropriate, select one or more options for each area within the panel. To chart by exception on the remaining panels, select the Unremarkable option to populate the first check box for each section (except Hallucinations, on which both Denied and None evidenced are selected). Choose another option in any of thComplete the Mental Status Exam Template
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On the Presenting Concerns panel, do one of the following actions in the Written HPI narrative field: Use the client's words to document the symptoms and presenting issues that prompted a visit to the office. Use the My Phrases functionality. Click Add. Click Save & Close. Parent topic: BH - Brief Assessment TemplateRecord the Client's Presenting Concerns
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To finalize billing, navigate to the Behavioral health billing section. For the End time field, do one of the following: Click the clock button to enter the current time. Click the field to type the time that marked the end of the exam. Note: The read-only Duration field fills after the entry of the End time. If appropriate, select the option for Service performed by. Note: A stored procedure that works with the Service Code Mapping system template calculates a service code based on selected practice, payer, visit type, licensure, and the time-based calculation. The stored procedure launches an alert if E&M coding or other additional coding is required. The system fills the fields with the name of the current user and fills the Service Description and Service Code fields if a mapped service code is found. To select a different service description/code or if no matching service code is found click the Service description field to select a code in the Service Item Mstr picklist. To addreFinalize Behavioral Health Billing
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The Mental Status Evaluation panel enables you to enter a narrative description, including the client's appearance, mood, affect, speech, thought process/content, cognition, and insight/judgment. Use the Mental status exam link to document a more comprehensive record. Complete the Mental Status Exam Template Parent topic: BH Hx Section Tab Overview Parent topic: BH - Psychiatric EvaluationMental Status Evaluation Panel
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To record information on the Mental Status Exam panel, record a response to the question Does the individual require a full Mental Status Exam? Select Yes for a comprehensive record and click the Mental Status Exam link. Select the No if a full status exam is not necessary. Note: It is up to the provider to determine if a full mental status exam is required. Indicate whether there has been No significant change or No notable change in the following areas and type any notable change in the adjacent fields: Mood/affect Thought process/orientation Motor activity and speech Behavior/functioning Medical condition Substance use/addictive behavior Select the Not applicable check box if substance use or addictive behaviors do not apply to this client. Click the Substance Use link to open the BH Substance Use Assessment template. Parent topic: BH - Psychopharm TemplateRecord Mental Status Exam Information
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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