1. Look up a Patient using the patient icon.
  2. Open Packet Navigation from your preferred templates and add the program.
  3. Click to open the 'Screening Note' (BH) template from Packet Navigation.

Plan/Additional Information/Discussion

  1. Add a comment in the Plan/Additional Information/Discussion

Assessment/Diagnosis

  1. If the client has a diagnosis, you will click the 'Active Diagnosis' link; highlight a diagnosis from the active diagnosis grid; click Add to Grid; click close. If the client does not have a diagnosis you will click on the 'Diagnosis Code Lookup' link and search for the diagnosis, highlight the diagnosis in the list and click select.

 

 

  1. If there is more than one Active Diagnosis in the active diagnosis list add them (if applicable)

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  1. Add 'Status, Severity, Impression and Specifier' (only add information to these sections if it is applicable)
  2. If the diagnosis in the grid needs to be re-organized - click the sort of button on the bottom to arrange them in the order needed.

 

 

 

Charges

 

  1. Click on the link 'Interpreter, Cultural, Counseling Details' to open the 'Counseling Details' popup.

Table Description automatically generated with low confidence

  1. Complete each section that is applicable and click save and close - if nothing needs to be documented you can click cancel to close the window.
  2. Click on the down arrow next to 'Start Time' and add the time started; select AM or PM; click ok
  3. Click on the down arrow next to 'End Time' and add the end time; select AM or PM; click ok
  4. Click in the 'Service Code' box and choose the appropriate service code, click ok
  5. Click the 'Submit Code' button and if the document does not automatically generate click the generate button.
  6. Review the document for accuracy

Graphical user interface, application, Word Description automatically generated