Southern Indian Health Council

1. Open Packet Navigation from your preferred templates and add the program.
2. Click to open the 'Progress Note' (BH) template from Packet Navigation.

Individuals Present

1. Click in the 'Contact Type' field and choose from the pick list provided, click ok.
2. Add a Reason for Contact.
3. Click the radio button to select if Individual was present or not, If not present select reason not present.
4. Click in the 'Others present' field (as if others were present.)
5. Click in the grid to choose a support resources listed and if there is no one listed in the grid, type the name of a person that might be present.
6. Check the box to 'Include Support Resources on Document.

Current Assessment

1. Click in the radio button that best fits the 'Individual's Progress'
2. Click the blue link to the right to open the 'Mental Status Exam' popup and complete the section by clicking on the appropriate boxes for each section that best fits the client’s mental status in today's visit, click ok to return to the template
3. Click in the 'Individuals report of progress' field and document the information regarding the client’s progress towards the goals/objectives since last session. (if applicable)
4. Click in the 'Client presented with SX' field and document if the patient presented with any symptoms (if applicable)
5. For each 'Individual Condition' in this section click in the radio button that best fits this visit and if there is notable change add the information in the comment boxes provided.
6. Click on the 'Substance Use' link to open the substance use popup and complete each section if applicable. Click ok when finished to return to the template.
7. Click on the 'Suicidal/Homicidal Risk' link to open the safety risk and answer those questions (if applicable) and click save and close to return to the template.

Barriers to Care

Goals, Objectives, and Interventions Addressed Today 

*New Goals and Objections cannot be added or updated from this template, they can only be added or updated in the 'Integrated Service Plan'

1. Click in the 'Goal today' field and pick the goal from the pick list provided of any goals that were discussed with the client during this visit.
2. Click in the 'comment' field and click add so it appears in the grid.
3. Repeat the steps above if there are more then one goal being discussed in this visit.
4. Plan/Additional Information/Discussion
5. Click in the 'Plan/Additional Information/Discussion' field to add the discussion that took place with client during this visit.

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