Southern Indian Health Council

BH Brief Assessment 

1. Lookup a Patient using the patient icon.
2. Click the template icon and open the 'Packet Navigation' template from the list .
3. Add the patient’s program to the program field.
4. Click to open the 'Brief Assessment' (BH) template from the Packet Navigation.
5. Confirm the correct template opened.
6. Add a checkmark to the Discussed confidentiality and obtain consent for care.

Click on the History Summary link.  A template open.  Add information as desired than save and close the popup to return to the template

1. Click on the Transitioning into Care link – A will template open. Add information is desired then save and close the popup to return to the template.

1. Click in the 'Reason for contact' field and choose the reason from the picklist provide.

1. Mark if Individuals is Present
2. Click in the 'Contact Type' field and choose the contact type from the picklist
3. Click in the field that best fits the patient was present of not present
4. Click in the field for 'Others present' and click in the 'Support Resources' section to populate a name in the other present field.
5. Click the 'Add' button for support resources and add a new support resource in the popup window that opens. Fill in t the necessary information.
6. click save than close

Presenting Concerns

1. Write a HPI narrative in the memo field provided - feel free to click on My Phrases and use phrases if you have any created

Substance Use/Addictive Behavior

1. Click the 'Substance Use' link and complete the panels in the popup provided including the link for 'Tobacco Usage'. Click save and close to return to the template

Trauma History

1. Click in the radio buttons that best fit the trauma history and enter comments regarding the details of the trauma.

Mental Status Evaluation 

1. Click the 'Mental Status Exam' link to open the mental status popup

1. Complete each panel by adding a check mark for the mental status for each section
2. Add a Summary of your positive findings in the summary field
3. Click 'ok' to return to the template.
4. Write a written narrative of the Mental Status in the memo field.

Risk Assessment

1. Click the blue 'Suicidal/Homicidal Risk' link and answer the questions then click save & close to return to the template.

1. Click the 'Safety Risk' link to open the functional needs popup and enter information for a CN, as evidenced by and yes.

1. Click ok to return to the template

1. Click the 'Columbia Suicidal Severity Rating Scale (C-SSRS) link and complete answer the questions in the Columbia Suicidal Severity Rating Scale, click save and close to return to the template.

1. ONLY add a check mark to the 'Patient is not currently a danger to self, other or property if the person has no past or current risks. Click add so it appears in the grid below.
2. Click in the 'Risk' field and select an item from the picklist provided
3. Click 'Current or Past' for this risk
4. Click in the 'Event date' field and select a date; add a check mark to the box if the date is approximate
5. Answer the remaining questions by clicking yes or no
6. In the 'Describe plan/attempt' field add a comment
7. Click the add button to add the information to the grid, repeat if there is more then one risk.

1. Add a comment to the 'Safety Management Plan' if appropriate

Goal, Objective, and Intervention Information

1. Click on the 'Clinical/Functional Needs' link on the right side to open the 'Assessed Needs' popup

1. Click on each of the blue links to review the assessed needs previously documented.
2. Click close to return to the template

1. Click in the field for 'Linked to assessed need'; click on one of the needs listed; click ok
2. Click in the 'Goal' field and add the goal
3. Click in the 'Objective' field and add the objective
4. Click in the 'Current Measure' field and add the current measure
5. Click in the 'Desired Measure' field and add the desired measure
6. Click in the 'Service description/modality field and choose from the picklist the service that best fits this goal.
7. Click in the 'Functional area' field and add a functional area (if applicable)
8. Double click in the 'Individuals Strengths' field to open the picklist of the client's individual strengths that were previously added.
9. Click in the 'Potential barriers' field, click cancel then add a barrier (f none are available)
10. Click in the 'Supports, Resources, etc.' field and add the supports needed for this goal.
11. Click in the 'Intervention' field and add an intervention (if applicable)
12. Click in the 'Frequency' field and add from the picklist
13. Click in the 'Responsible' field and select from the picklist; click ok
14. Click in the 'Date of expected accomplishment' field and add a date
15. Click the 'Goal Status' as New
16. Click 'Add' to add to the grid

1. Repeat steps above to create several goals for each assessed need
2. Click the filter options to see the goals/objectives for 'Program' (if client is enrolled in more than one program)
3. Add a 'check mark' to the Include only active goals on document
4. Click on 'Lab/Radiology Order Processing' link template will open. save and close to return to the template 
5. Click on any of the items on the left to review the orders
6. Click on the 'Follow Up' button.

1. Click in the 'Plan/additional information' section and type what took place during this session.

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. 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.

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