AVATAR ASSESSMENT DISCHARGE/TRANSFER .3. Avatar CWS Manuals for Clinical Users and Avatar PM Manuals

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Transcript of AVATAR ASSESSMENT DISCHARGE/TRANSFER .3. Avatar CWS Manuals for Clinical Users and Avatar PM Manuals

  • AVATAR

    ASSESSMENT&DISCHARGE/TRANSFER

    REFERENCEGUIDE

  • L:\1QUALITYMANAGEMENT\QIAvatarTraining\FinalManuals\AssessmentsAvatarReferenceGuide 2

    http://smchealth.org/avatar

    IncludesUpdateClientData;ClientRelationships;ClientAlertsandUrgentCarePlan

    3.AvatarCWSManualsforClinicalUsersandAvatarPMManualsforAdministrativeUsers:

    www.smchealth.org/onlinetraining

    AvatarProgressNotesforBHRSAvatarClientTreatment&RecoveryPlanforBHRS

    2.OnlineTraining:IntroductiontotheAvatarElectronicMedicalRecordAssessments,Discharges&TransfersforMentalHealth

    1.BasicDocumentationTraining/BHRSDocumentationManual:FormoreaboutAssessments;Diagnosis;MedicalNecessity;LOCUS/CALOCUS;Timelines;AssessmentLocationandServiceChargeCodesandProgressNoteshttp://smchealth.org/sites/default/files/docs/BHS/QM/BHRSDocManual.pdf

    ThelinksbelowprovideadditionalinformationrelatedtoAvatarandAssessments:

    IMPORTANT

  • L:\1QUALITYMANAGEMENT\QIAvatarTraining\FinalManuals\AssessmentsAvatarReferenceGuide 3

    TABLEOFCONTENTS

    CONTENTAREA PAGE

    Section1.TheCompleteAssessment 4

    Section2.TypesofAssessmentsandTimelines 5

    A.TypesofAssessments 5

    AgeGroup 5

    TimeFrame 5

    Master 5

    Annual/UpdateAssessment 5

    SpecialAssessment 5

    PhysicianInitialAssessment 5

    AssessingTeam/ReceivingTeam 5

    B.AssessmentTimelines 6

    AdmissionAssessmentTimeline 6

    AnnualAssessmentTimeline 6

    AssessmentUpdates 6

    Section3.WhoCanPerformAssessmentFunctions 7

    A.AssessmentScopeofPractice 7

    B.CoSignatureProcess 78

    Section4.TheAssessmentBundle 9

    MenuPath 9

    IMPORTANT/TIP 9

    A.MasterAssessment 1012

    B.BHRSDiagnosis 1316

    C.MentalStatusExam 1718

    D.LOCUS/CALOCUS 1920

    E.SubstanceAbuseAssessment 2021

    Section5.FindingtheSTATUSofAssessments 22

    DocumentationataGlanceReport 2223

    DashboardReport 2324

    Section6.FindingCompletedAssessments:ChartReview 24

    Section7.DischargeandTransferProcess 2528

    Attachment1:AboutAnniversaryDates 29

  • L:\1QUALITYMANAGEMENT\QIAvatarTraining\FinalManuals\AssessmentsAvatarReferenceGuide 4

    Section1:TheCompleteAssessment

    Mental Status Exam (MSE)

    Diagnosis

    LOCUS or CALOCUS

    Substance Abuse Assessment, if indicated

    Master Assessment Document

    EachassessmentdocumentthatisconnectedtotheMasterAssessmentmustbecompletedandfinalized(includingobtainingacosignature(s)fromyoursupervisor)beforetheMasterAssessmentcanbefinalized.ThecompleteAssessmentwhichincludestheMasterandupto4companiondocuments(asshown)aredueby60daysoftheAdmissionDate.

  • L:\1QUALITYMANAGEMENT\QIAvatarTraining\FinalManuals\AssessmentsAvatarReferenceGuide 5

    Section2:TypesofAssessmentandTimelines

    A. TypesofAssessments:AssessmentsarebundledbyAgeGroupandTimeframe(whentheyaredue).TheMasterAssessmentdocumenthasrequiredfieldswhicharethesameforeachtype;howevertheChild/YouthandPretoThreeincludemuchmoredetailincertainareas.

    TheMasterAssessmenthas3versions:1.)PretoThree;2.)Child/Youth;3.)Adult

    TheAnnual/UpdateAssessmenthas2versions:1.)Child/Youth;2.)Adult

    ThereisaSpecialAssessmentthatcontractagenciescompleteiftheyareasecondaryopenprogramtreatingtheclient.

    ThereisalsoaPhysiciansInitialAssessment(PIN)thatthePhysician/NPcompletes.ThePINmaybepartoftheassessmentthatthephysician/NPcompletesoritcanbeastandalonedocumentiftheclientisreceivingonlymedicationsupportservices.

    Usually,theclientrequiresonlyoneAdmissionAssessment.Ifaclientisopentomorethanoneprogramatthesametime,onlyoneprogramisrequiredtoperformtheAdmissionAssessment.

    Forclientsreceivingmedicationsupportservices,theMDwilleither:CompletetheMasterAdmissionAssessmentORCopytheMasterAdmissionAssessmentandappend(addto)itORCompleteaseparatePhysiciansInitialAssessment(PIN).

    AssessmentbyAssessingTeamForsomeprograms,therearespecializedassessmentteamsthatcompletetheAdmissionAssessment;otherwise,itistheprimaryclinician'sresponsibility.

    AssessmentbyReceivingTeamIfaclienthasalreadyhadanAdmissionAssessmentcompletedandthenisreferredortransferredtoanothertreatmentprogram/team,thecompletedAdmissionAssessmentmaybeacceptedbythereceivingprogram/team.Theclinicianatthereceivingprogram/teammustreviewtheassessmentandthenwriteaprogressnotetostatetheassessmenthasbeenreviewed.AnyadditionaloramendedinformationmustbecompletedonanAvatarUpdateAssessmentdocumentbyaclinicalstaffmemberofthereceivingprogram/team.

    Section3demonstratespartsoftheAdultMasterAssessmentandthecompanionassessmentformsthatmakeuptheAdultAdmissionAssessmentBundle.TheMasterAssessmentsfunctionandflowthesame,however,thereareadditionalfieldsinthePretoThreeandChild/YouthMasterAssessmentsthatarenotpresentontheAdultMasterAssessmentdocument.

  • L:\1QUALITYMANAGEMENT\QIAvatarTraining\FinalManuals\AssessmentsAvatarReferenceGuide 6

    B.AssessmentTimelines:

    AdmissionAssessmentTimelines:

    Sincetheadmissionassessmentmaytakeseveralsessionstocomplete,allcomponentsmustbecompletedby60daysoftheadmissiondate.IfdocumentsareinDraft(tobecompleted),orPending(awaitingacosignature),youwillseeanitemonyourToDolistasaremindertohavetheassessmentand/orcomponent(s)completedbeforetheduedate.

    Checkwithyoursupervisorregardinghowmuchtime/numberofvisitsyourprogramcalculatesforcompletingallassessmentdocuments.Someprogramshaveapervisittimeframe,somesupervisorslimittoacertainnumberofhoursforcompletingassessmentinterviewinganddocumentation.Alwaysgaugeyourtimebyobservingtheclientsand/orparent/guardiansabilitytosit,understandandbepatientwiththeassessmentprocess.

    AnnualAssessmentTimelines:TheAnnualAssessmentisrequiredtovalidateanddocumentanystatusquoorchangeintheclientspresentationofsymptoms,behaviorsanddiagnoses,aswellasthedevelopmentofadditionalstrengths.

    ThedocumentsthatarecompletedbytheCareCoordinatorandrequiredfortheAnnualAssessmentaretheAnnual/UpdateAssessmentdocument,theDiagnosisandtheLOCUS/CALOCUS.

    TheAnnualAssessmentmustbedoneatleastannually,andisdueon/beforetheanniversarydate.ThismeanstheAnnualcanbecompletedanytimeduringthesixweekwindowperiodpriortotheanniversarydate(butnotbefore).Ifaclientisopento2programs,onlyONEprogramcompletestheAnnualAssessment.

    AssessmentUpdates:Updatestotheassessmentcanbedoneatanytimeanddonotchangetheanniversaryduedate.Talkwithyourprogramsupervisortodetermineyourprogram'sassessmentprocess.PleaserefertoAttachment1,Page29,formoreinformationaboutAnniversaryDates.Alwayswriteaprogressnoteforyourtimeundertheservicechargecodeofassessment.

  • L:\1QUALITYMANAGEMENT\QIAvatarTraining\FinalManuals\AssessmentsAvatarReferenceGuide 7

    Section3:WhoCanPerformAssessmentFunctions

    A.AssessmentScopeofPractice

    Anyclinicalstaffmemberwhoisassessingtheclientcanperformassessmentfunctions.

    AmentalhealthcasemanagerwithaBAinPsychologycancompleteanassessmentbutcanNOTcompletetheMSE,Diagnosis,andClinicalFormulation.OnlyaLicensedPractitioneroftheHealingArts(LPHA)cancompletetheMSE,DiagnosisandtheClinicalFormulation.

    LPHAstaffinclude: MD/NP;andLicensed/Register/WaiveredClinicalPsychologist,ClinicalSocialWorker,

    MarriageandFamilyTherapist,andRegisteredNursewithMastersinPsych. TraineesinanyofthesecategoriesmayprovidetheDiagnosis;conductaMSE&Clinical

    Formulationwithacosignature.AnnualAssessmentsarecompletedbythecurrentCareCoordinator.

    B.CoSignatureProcess

    AnyassessmentdocumentsentforacosignatureisstillaDraftandcanbeedited.

    Onceanyassessmentdocumentiscompleted,theclinicianselectsthesupervisorintheSendTofield(A)andwritesabriefoutgoingcommenttothesupervisor(B).TheclinicianselectsPendingApproval(C)andsubmitstheassessmentdocument.

    A

    BC

    ThesupervisorwillreceiveaToDolistitemforeachdocumenttobeapproved/cosignedpertheclinician/traineesoutgoingcomments.

    This is what shows on the supervisors To Do list

    Forexample,theMSE,LOCUS,Diagnosis,SubstanceAbuseAssessment,ifindicated,andtheMainAssessmentwilleachhaveaseparateToDoitemsenttothesupervisorforapproval/cosignature.Thesupervisorreviewseachdocumentandapprovesitordoesnotapprove.IfthesupervisorselectsYes,(approves),thismakesthatspecificassessmentdocumentFINAL.Thesupervisormaynotifytheclinicianthedocumentwasapproved.IfthesupervisorselectsNo,(disapprove),thatassessmentdocumentrevertsbacktoDraftandAvatarsendstheDraftdocumentasaToDoitemontheclinician/trainee'sToDolist.TheclinicianwouldthenreviewthecommentsfromthesupervisorandupdatetheDraftdocument.Theclinicianthenresendsthereviseddocumentbacktothesupervisorforapproval.Thesupervisoronceagainreviewstherevisions,andonceapproved,thatdocumentbecomesfinalized.

  • L:\1QUALITYMANAGEMENT\QIAvatarTraining\FinalManuals\AssessmentsAvatarReferenceGuide 8

    SendingtheMasterAssessmentforCoSignature:OnceeachsupportingassessmentdocumenthasbeenapprovedbythesupervisorandisFINAL,theclinicianopenstheTabFINALIZEoftheMasterAssessmentdocument.Beforesendingtothesupervisorforapprovalandcosignature,eachoftheFINALsupportingassessmentdocumentsmustgetattachedtotheMasterAssessment.Toattach,selecteachassessmentdocumentinred,clickonthedropdownarrowandselectthecorrectFinaldocument.Itwillpopulatetheboxandshowthedateandclinician.(Iftheclientisnew,thereshouldonlybethedocumentthattheclinicianhasfinalized).Iftherehasbeenapreviousassessmentdocument,selectthecurrentappropriatedocumentforthisassessment.

    DropDown

    Youcanindicateotherstaffcontributions totheMasterAssessmentbyenteringtheirlastname,clickprocesssearch,thenselectsothatcliniciansnamepopulatesinthegraybox.

    SendtheMasterAssessmentasPendingapprovaltothesupervisor.AToDoitemissenttothesupervisortoapprove/cosigntheMasterAssessment.ThesupervisorreviewstheMasterAssessmentandclicksYestoapprove,orNotodisapproveandwhichrevertstheMasterAssessmentbacktoDraftandasaToDofort