Southern Indian Health Council

Concerns Tab

1. Look up a Patient using the patient icon.
2. Add a new encounter if not using a check-in appt.
3. Open Packet Navigation from your preferred templates and add the program.
4. Click to open the 'Comp Assess - Concerns' template from Packet Navigation.

Individuals Present

1. Click in the 'Contact Type' field and choose from the picklist provided.
2. Click in the 'Reason for Contact' field and choose from the picklist provided, click ok. 
3. Click the radio button to select if the Individual was present or not; If not a present select reason not present.
4. Select the 'Others present' check box.
5. Click in the grid to choose the 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'.

Presenting Concerns

1. Click in the 'What are you seeking help for today' box and add a narrative.
2. Click in the 'How long have these issues been a concern' box and add a narrative. (not required field)
3. Scroll back to the top of the template to proceed with the next tab.

Social Hx Tab

Living Situation

1. Click in the field for 'Where is the individual currently living' and highlight an item from the picklist; click ok; verify the selection you made is in the box
2. Click in the field for 'Residential care/treatment facility 'and highlight an item from the picklist; click/ verify the selection you made is in the box
3. Click Y/N for 'At the risk of losing current housing' and add a comment
4. Click Y/N for 'Satisfied with the current living situation' and add a comment
5. Click the Add/Update button for Residence and check a box(es); click Save & Close; confirm what you selected is in the box
6. Click in the comments box and add a narrative
7. Click on the blue link 'Activities of daily living and add a functional need in the popup window. Be sure to click in the radio button for 'CN', add something in the 'As evidenced by' box, and click the 'yes' radio button. When finished click ok on the bottom of the window. 

Family Information

1. Click yes or no for 'Does the individual have children? And if there are children add the names to the boxes and click the add button, so the names appear in the grid. 
2. If appropriate, click in the 'Describe the relationship you are involved…' and add a comment. – Not required 
3. Family history of mental illness and/or substance abuse: click the add button and select relationship, add person name and select one of the options; save to grid, save & close; confirm the relationship is in the grid
4. Click in the field for 'Pertinent family medical, mental health…: field and add a narrative. – Not Required 

Development

1. Click in the Developmental history field and add a narrative. (Not Required)
2. Click Yes or No for 'Has individual been previously diagnosed with a developmental disability; add details in the box below if you answered yes. (Not Required) 

Abuse/Sexual Risk Behavior

1. Click No or Yes for 'Do you feel save in your current living situation' and add a comment if you chose no.
2. Click Yes or No for 'Are you currently or have you ever been hurt, harmed….' and add a comment if you clicked yes.
3. Click Yes or No for 'Is a member of your household/family currently being or has been harmed….' and add a comment if you clicked yes.
4. Click Yes or No for 'Do you engage in any sexual behaviors ….' and add a comment if you clicked yes. 

Social Supports

1. Click in the field for 'Friendships/social/pets/peer support' and add a comment.
2. Click in the field for 'Meaningful activities' and add a comment.
3. Click in the field for 'Religion/spirituality to highlight an item from the picklist; click ok to return to the template. Click in the 'Religion/Spirituality' comments field and enter information regarding the client’s religion and/or spirituality. 
4. If there is no race in the box - double click and add a race from the picklist provided, click in the 'Race Comments' field to add information regarding the client’s race. 
5. Click in 'Race comments' and add a comment.
6. Click in 'Community supports/self-help groups' and add a comment.
7. If the PCP box is empty - click in the box and choose a name from the picklist provided (it’s okay that it is not an actual PCP just for testing). 
8. If the 'Preferred Language' is empty, click in the box and choose a preferred language from the picklist provided. 
9. If the 'Ethnicity' box is empty - double, click in the box, and add an ethnicity. 
10. Click in 'Cultural 'ethnic information ' and add a comment
11. Support Resources: Click in each field and add information; for relationship highlight an item from the picklist and click ok; add an effective date; add a comment; click add; confirm the person you added is in the grid.

Legal

1. Status: answer yes or no to both questions and if yes explain the status in the comment boxes. 
2. Answer yes or no to the question for involvement history and enter a comment in the box provided. 

Education - Adult - skip if your client is a child 

1. Answer the questions regarding the 'Education History' and enter a comment in the box provided. 
2. Education - Child/Adolescent - skip if your client is an adult.
3. Click Y for 'Regular education classroom'.
4. Add a name of a school; click in the 'current grade' field, highlight an item from the picklist; click ok; confirm your selection is in the box.
5. Education classification' check some of the boxes.
6. Click in the 'Comments on past and current academic functioning' field and add a comment.
7. Click in the 'Test or other evaluation results' and add a comment.
8. Click in the 'Attendance' field and add a comment.
9. Click in the 'Previous grade retention' field and add a comment.
10. Click in the 'Suspension/expulsion' field and add a comment.
11. Click in the 'Additional barriers to learning' field and add a comment.
12. Click in the 'Peer relationship/social functioning' field and add a comment.

Employment Status

1. Enter the number of hours worked per week - leave blank if none.
2. If not currently employed: answer the questions in this section. 
3. Enter comments regarding the client’s employment status. 
4. If no employment is visible in the grid and you would like to update this section - add the information in the boxes above the grid and click add. 

Military

Trauma History

1. Click 'none reported' if the client has no trauma history
2. If there has been trauma - click the no or yes options for each item listed 
3. Click in the field for 'Provide relevant details and add a comment
4. Scroll back to the top of the template to proceed with next tab

BH HX Tab

Past Medical/Surgical

1. Click the Add button under the grid; click on the radio button to select a medical condition; add the onset date (if you have it) click add to the grid.
2. If the client reports any previous surgeries - follow the same steps as above to add to the grid when finished click ok to return to the template. 

Substance Use/Addictive Behavior History

1. If there is no substance use or addictive behavior click the box for 'None reported'
2. Click the 'Substance Use' link on the right to enter the client’s substance use 
3. Open each panel in the window to document if applicable. For substance use, you will click in the primary box to open a picklist for each box to choose the best fit for the substance use being recorded (continue for each substance use recorded) 
4. Tobacco Usage: Click on the blue link for Tobacco Use and complete each section that pertains to this client. Click ok to return to the previous template. 
5. Complete each panel in the BH Substance Assessment window if it pertains to this client. Click ok on the bottom of the window to return to the Comp Assessment. 

Mental Health and Addiction Treatment Service

1. Click in 'Type of service; highlight from the picklist; click ok; add a service start date and end date; add a reason; add an agency name; click In or Out for the type of treatment and click yes or no if the treatment was completed. Click the add button so the information appears in the grid. 
2. Complete the sections for 'Outpatient or Inpatient’ and for ER/Detox section of the template.
3. Click in the 'What was helpful with past treatment' field and add a comment.
4. Click in the 'What was not helpful' field and add a comment.
5. Click in the 'Additional comments' field and add a comment.

Medication Information

1. Click the Add button to open the Medication Allergy window to add an allergy for the patient. 
2. Click on the magnifying glass in the window and add a few letters to the search to find an allergy. Click on an allergy in the list and click ok to return to the previous window. 
3. Click the add button under reactions to add the reaction for the allergy and click ok. 
4. Click the add button on the right of the window to add the allergy to the list in the Medication Allergy window then click the 'x' on the top of the window to close. 
5. Skip if you will not be adding medications to the Medication Module: If adding an active medication to the Medication Module - you will double click in the grid to open the Rx Module and add a medication. Close the Rx Module to return to the Comp Assessment.
6. Any medications that will not be in the Rx Module can be added to the 'Other Medications Reported by Patient' section. Add the information to the boxes provided and click add. 
7. Add information to the comment box regarding the client’s past medications. 

Mental Status Evaluation

1. Choose one of the two steps below to complete the Mental Status Evaluation 
2. Click the blue 'Mental status exam' link; add check marks to each panel and enter a summary in the summary box provided and click ok (information from this option will only appear on the generated document). 
3. or you can write a narrative in the box provided (both of the options will appear on the generated document). 

Risk Assessment

1. Click the blue 'Suicidal/Homicidal Risk' link and answer the questions then click save & close to return to the template.
2. ONLY add a checkmark 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. 
3. Click in the 'Risk' field and select an item from the picklist provided.
4. Click 'Current or Past' for this risk.
5. Click in the 'Event date' field and select a date; add a checkmark to the box if the date is approximate 
6. Answer the remaining questions by clicking yes or no. 
7. In the 'Describe plan/attempt' field add a comment.
8. Click the Add button to add the information to the grid, repeat if there is more than one risk. 
9. Add a comment to the 'Safety Management Plan' if appropriate.

Past Risk and Alerts

1. Answer Y/N to all of these questions; If yes, add a comment or date where appropriate
2. Click the 'Safety Contract' button to generate the safety contract document for the client if appropriate. 

Screening Tools

1. Click yes or no if a screening tool was used for this patient at this visit. 
2. Click the 'Screening Tools' link to access the screening tool window.
3. Click on any screening tool listed and answer the questions, click okay so the information appears in the screening tools grid. Click save and close to return to the template. 
4. Scroll back to the top of the template to proceed with next tab.

Assess/Plan Tab

Life Goals, Strengths, Abilities, and Barriers – (Not required) 

1. Click in 'Life Goals' field and add a comment.
2. Click in 'Strengths' field and add a comment.
3. Click in 'Abilities' field and add a comment.
4. Click in 'Barriers' field and add a comment.
5. Click in 'Past and present successes in achieving desired goals' field and add a comment.

Barriers to Care

Service – (Not Required)

Clinical Formulation/Interpretative

1. Check the boxes that best fit the clinical summary information provided by any of the individuals listed and enter the name in the boxes provided if it is not the client. 
2. Click the 'Interpretative summary' field and add your interpretative summary for the Comp Assessment.

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