Visit Types for Comprehensive Assessment

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Assess/Plan Section Tab

The Assess/Plan section tab for the Comprehensive Assessment template set enables you to document the client's life goals, strengths, service preferences, as well as the assessment and treatment recommendations for the client. The Assess/Plan section tab has six panels: Life Goals, Strengths, Abilities and Barriers Service Preferences Clinical Formulation/Interpretative Summary Assessment/Diagnosis Treatment Recommendations/Assessed Needs Signatures This template also includes the Start and End functionality along with the ability to print the Comprehensive Assessment note. Enter Life Goals, Strengths, Abilities and Barriers Enter Service Preferences for the Client Record Who Supplied the Clinical Data and Provide an Interpretive Summary Enter Assessment and Diagnosis Details Enter Treatment Recommendations Enter Document Signatures Parent topic: Comprehensive Assessment Template Set

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Intake Process for Comprehensive Assessment

The intake process is designed to be completed over several visits if needed. The Comprehensive Assessment templates can be accessed on a future encounter to finish the intake. If this documentation represents a new problem or the recurrence of an old problem, the New Intake button is used. When selected, a confirmation window states that you are about to clear data. Selecting Yes indicates that you are beginning a new episode of care. The historical data still exists in the past encounters. Start a New Intake Record the Client's Presenting Concerns 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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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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Comprehensive Assessment Template Set

The workflow of a comprehensive assessment is a set of five templates that enable you to perform a complete intake evaluation for either an adult or pediatric, Behavioral Health clients. The comprehensive assessment is meant to be completed by a clinician designated by the practice. This occurs during the agency’s intake process. From the Comp Assess tab is also known as the BH CA Presenting Concerns template. The following templates that make up the Comprehensive Assessment Template set are accessed through a section tab menu: Concerns Social Hx Bh Hx Functional Assess/Plan Visit Types for Comprehensive Assessment Access the BH CA Presenting Concerns Template Intake Process for Comprehensive Assessment Social Hx of a Comprehensive Assessment BH Hx Section Tab Overview Explanation of the Functional Section Tab Assess/Plan Section Tab Parent topic: Intake Visits for Behavioral Health

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Visit Types for Psychiatry Evaluations

The Psychiatry Eval tab is available from the following Visit Types: Chart Abstraction Chart Update Hospital Consult Intake No Medical Services Intake with Medical Services Medication Management with Psychotherapy Medication Management with Psychotherapy & Translator Onsite Consult Psychiatric Diagnostic Evaluation Psychiatric Evaluation with Medical Services Parent topic: BH - Psychiatric Evaluation