SBHG EMR Training Assessment User’s Guide Users EMR Manual 12... · 2012. 1. 8. · A PDF view of...

SBHG EMR Training Assessment User’s Guide

SBHG EMR Training ~ Assessments ~ of 24 vol.1

Welcome to the Assessment Users Guide of the EMR Training.

At the completion of training you will be able to: • Complete The Initial Child Assessment in the EMR • Complete the Annual Assessment Update in the EMR • Complete The Child Initial Assessment Addendum in the EMR

Enter the EMR. • Click the Internet Explorer icon

• Click into the training environment

• Login using the user name and password on the laminated login card

Click on Return to Main

Select your client

1. Click on the Client Module

2. Click on Select Client

3. Enter Search criteria o If you do not remember how to spell the client’s name, you can either

1. Type in the percent symbol % which brings up all the names of client’s you have access to

2. Type in part of the last or first name

4. Click on your client’s name

I. ENTERING AN ASSESSMENT

Entering a New Assessment:

Before you try to open a new service: Make sure you open the drop down menu directly under the “Service Entry” tab and select “All Programs __Your Name__Has Access To”. Remember: You can access blank forms from different locations in the EMR: 1. The Navigation Bar

OR: 2. The Enter New Service box: (we’re only showing you this way in the Manual)

SBHG EMR Training ~ Assessments ~ of 24 vol.1 Under Case Management in the Client Module


tomatically taken there)

1. Click on “Service Entry”(unless you are au

To add a new Child Initial Assessment click on “Enter New Service”:


CHECKLIST OF REQUIRED FIELDS FOR THE CHILD INITIAL ASSESMENT

Actual Date

rals

□

□ Time of Day

□ Face to Face Time

□ Other Time

□ Total Time (Auto Adds-Not Modifiable)

□ Service Site

□ Number of Family Collaterals

□ Number of Non-Family Collate

□ Informant

□ Program Providing Service

□ Facility Providing Service

□ Allergies

Presenting Problems: This is information obtained at the time of admission. It’s not modifiable but the information will be displayed in the Assessment.


BILLING TIPS

SESSION 1: BILL UNDER THE “PROVISIONAL CARE PLAN” (PCP). INCLUDES TRAVEL TIME, SERVICE TIME AND DOCUMENTATION TIME FOR THE PCP ENTRY

SESSIONS 2 – WHATEVER IT TAKES TO COMPLETE THE ASSESSMENT AND CARE PLAN: BILL EACH SESSION INDIVIDUALLY AS THE ACTUAL SERVICE PROVIDED. USE OBJECTIVES AND INTERVENTIONS FROM YOUR COMPLETED AND APPROVED PROVISIONAL CARE PLAN. INCLUDE TRAVEL AND DOCUMENTATION TIME

ASSESSMENT EMR FORM: BILL ONLY THE TIME IT TAKES TO ENTER THE INFORMATION INTO THE EMR EVEN IF IT TAKES YOU SEVERAL DAYS TO COMPLETE IT. FACE TO FACE, FAMILY COLLATERAL AND NON FAMILY COLLATERAL SHOULD ALL BE ZERO.

Fill In required billing information: (Refer to Phase I EMR Training Manual for more details)

6. Click on “Service Site


1. Actual Date: The date you fill out the Child Initial Assessment. 2. Time: The time of day

you start completing the form

Use the drop down menu

for the dates

3. Face to Face Time: This should be “0”(zero) when you actually complete the Assessment in the EMR

4. Other Time: The time it takes you to complete the form in the EMR

5. Total Time: Auto Adds

The Service Site should always be Clinic/Facility/Office

For filling out the Assessment

7. Number of Family Collaterals: Should be zero when you complete the Assessment in the EMR 8. Number of Non-Family Collaterals: Should be zero when you complete the Assessment in the EMR

XXXXXXXXXXXXX


10. If the School information is not already loaded into the system you have 2 choices:

1. Don’t enter anything here. It’s not a required field. 2. Enter all of the school information. If you do not enter ALL of

the School information you won’t be able to save the form.

9. If you need to submit this form to anyone OTHER THAN YOUR SUPERVISOR, click on the “Submit To” button and select the person from the drop down menu

11. Fill in the names of your primary informants. Remember: This is a Required Field

12. Start filling in your Assessment information: Very Important Hints:

□ The spell check is the box below each section

□ Do not put in ANY symbols or you will not be able to save the Assessment (ex: %, #, @, [, ], $, &, *…)

□ Do not cut and paste from Word. This may cause an error message and may result in you losing the data that you just entered!

□ Fill in all required fields first and save the document. Then save it often (about every 10‐15 minutes.

Hint: This is the same information you enter in the Client Care Plan Symptoms/Behaviors Section


This information is real important and should be the used to confirm the certainty

of an included diagnosis in the DSM!

13. Follow the instructions when you need to check appropriate boxes:

14. Elaborate when directed to so:

15. Be sure to ask the really important questions. Ex: Don’t say; “Client appears to have no homicidal ideation. Say something like this; “Client and Caregiver deny any homicidal ideation or intent at this time”


If you check “No” for any question in the Assessment you don’t need to elaborate. It is also not necessary to write N/A in the elaborate field when the answer is “No”.

16. Read carefully what information you are being asked to supply. In the example below you would include any needs or expectations within the context of the culture of the client and/or the client’s family.

17. The Mental Status Exam (MSE) is a very important part of any Mental Health Assessment. It’s a combination of observation and direct feedback to your questions. Be sure you ask about anything you can’t directly observe (ex: hallucinations and suicidal ideation). Also, make sure anyone reading the information you put in Assessment knows you asked a question.

Ex: “Client and Caregiver deny any Homicidal or Suicidal Ideation”


Ex: Client is involved with gang members who use drugs and alcohol. Client also rejects his parent’s culture of origin and religion. Parents are devout Catholics and think their son’s gang activities are sinful and wrong. Client refuses to speak Spanish in his home and his mother is mono-lingual (Spanish). This makes the client’s father very upset. Parents expect Star View to stop the client from associating with gang members, make him respect his parents and his culture/religion or origin.

18. Filling Out the Developmental Milestones Section:

Example A. Single select vs. Multi‐select

Multi‐select has the directions “Check all that apply”

Example B. “Single Select”:

Example C. NUMBER ONLY FIELDS – if information is entered incorrectly then you will receive an error message and will not be allowed to save the document.

Under “Term: Mos “ and “Birth Weight (lbs)” only type in whole numbers. Do not type in “months” or “lbs” or any other words after the numbers. These are number fields only and will not take any words.

Importan!t: If Term: Mos or birth weight is unknown leave 0 in these fields.


Example D. Enter Whole Numbers Only: You can’t enter something like “4.5” Do not type the word “hours”

Example E. Fields asking for a Telephone number: enter only the 10 digit number (i.e. 5625551212), do not add dashes – or parenthesis ( ) (i.e. (562) 555‐1212 or 562‐555‐1212).

F. Completing Developmental Milestones: You only need to complete up to clients age, it is not necessary to write N/A in the remaining boxes. Example: If your client is 10 years old, you do not need to type N/A in the fields for clients 12‐on.


If you are unable to assess any part of the Developmental Milestones section, check the “unable to assess box

Explain the “Reason” you are unable to Assess in the dialogue box that opens when you click on the “Reason” box

Do Not use the Remarks box to add more information. It is not easily accessible to the supervisor

19. The Summary and Diagnosis section should match the info you put in the rest of the Assessment.

20. Enter the Co‐Occurring Disorder Code by clicking on this line and opening the drop down menu. It’s hard to see but if you hover your pointer over the line, your pointer will turn into a hand.

21. Select the appropriate Co‐Occurring Disorder Code from the drop down menu: Refer to page 16 for decision rules for selecting the correct Co‐Occurring Disorder code.


Hint: Read what they are asking you to put in this section!

Substance Codes

Alcohol AL Amphetamine AM Cannabis MJ Cocaine CO Hallucinogen HA Inhalant IN Sedative/Opiate SO Poly-Substance PS (Whenever 2 or more substances are used)

THE NEXT 2 PAGES CONTAIN THE FOLLOWING DOCUMENTS:

1. MEDI‐CAL INCLUDED DIAGNOSIS

2. DUAL DIAGNOSIS CODE DECISION TREE


22. Identify the source of the diagnosis (It will usually be “Agency Waivered/Licensed Clinician). 23. List the date of the diagnosis. Use the drop down menu.

24. Fill out the Disposition/Recommendations/Plans section:

25. Check all the boxes that apply to see if the client meets the criteria for TBS Services:

26. The “Allergies” section is a required field.


Ex: Client meets medical necessity for treatment. Initial plan is to meet with client for Ind. Therapy 1x a week, assign SC to conduct Ind. Rehab/Skill Building 1x a week to work on anger management skills and make referral for Psychiatric Assessment. Client might also benefit from referral to MST program, so will discuss possible participation in that EBP with MST Supervisor.

Complete Billing/Encounter Fields:

30. Click on “Facility Providing Service” and a drop down menu will appear. Select the facility you are from, not the facility the client is from


27. Do Not check the “Exempt from Billing” box unless instructed to do so by your supervisor! 28. Click on “Activity Type” and select the appropriate choice from the drop down menu

Make sure you select the correct Facility!

29. If the client is NOT involved in this service uncheck this box

32. Printing the Assessment: (If Needed) Click on “Print” Then Click on “Print Form”

A PDF view of the assessment will open. Click “Print”.


31. As with all forms in the EMR, once you’ve entered all the required information (in bold text) you can save the form as a draft. Be sure to save the document before you hit close or “X” out of the form.

A print box will open where you can select which printer to print. NOTE: always make sure that the “All” page range is checked otherwise a blank page will print.

II. ENTERING AN ANNUAL ASSESSMENT UPDATE You can find the Annual Assessment Update in the EMR the same way you found the Child Initial Assessment


1. Enter the same way you entered this information for the Initial Assessment EXCEPT: You would include Face to Face, Travel and Documentation time due to providing the required face to face meeting. 2. You also need to list the Family and Non-Family Collaterals at your face to face.

You should see “Annual Assessment Update” here

XXXXXXXXXXXXX

Cultural Competency Information: Language/Translation


3. Enter the client’s Primary Language 4. Answer the next 2 questions. It’s very important to answer these accurately!

5. This should be identical to the symptoms/problems listed in the Care Plan Update!

6. Don’t forget to list Cultural information here!

7. Be sure to answer this question correctly

8. The Medical Necessity Section is very important so give it a little thought before filling it out (see example below).

9. Fill Out Billing/Encounter information:


Now That’s Medical

Necessity!

10. Use the same instructions for the Child Initial Assessment to fill this out. Except: 11. Click on the “Encounter With” box and select the appropriate choice from the drop down menu

12. Complete Progress Note

III. ENTERING A CHILD INITIAL ASSESSMENT ADDENDUM You can find the Child Initial Assessment Addendum in the EMR the same way you found the Child Initial Assessment

1. Enter billing and encounter information the same way you entered this information for the

Child Initial Assessment 2. You must check the appropriate box/boxes when you add an Addendum to the Child Initial Assessment:

4. Save your document as a draft copy and/or save it then submit it to your Supervisor for approval.


Ex: “Completed Annual Assessment Update on 9/25/2008, please see above information”

3. You don’t need to use a particular template for the Progress Note but you must specifically list what information you are adding to the Child Initial Assessment or changing in the Child Initial Assessment

SBHG EMR Training Assessment User’s Guide Users EMR Manual 12... · 2012. 1. 8. · A PDF view of...

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