Southern Indian Health Council

1. Click the template icon and open the 'Packet Navigation' template from the list 
2. Add the patient program to the program field 
3. Click to open the 'Integrated Service Plan' (BH) (ISP) from the Packet Navigation template
4. Click 'Initial' or 'Annual/Update' (this would depend on if this is the first time vs. at annual or an update)

Family Vision/Treatment Involvement

1. Enter who is at the Service Planning Meeting. 
2. Enter the Recovery Goal/Person-Family Vision.
3. Enter the reason they would like to participate in the program/activity.
4. Enter what the client/family says needs to have happened in order to leave services. 
5. Click Yes or No for 'Does the client want anyone involved in treatment at this time?
6. If there are no resources in the grid, click Add to open the support resource popup; add a resource; click save, and then close to returning to the template.
7. If the resources in the grid need to appear on the document, add a checkmark to the box that says, 'Include Support Resources on Document'. 
8. Person's Strengths - Click in each field selected from the picklist provided and click Add (repeat if needed to add more than one strength.)

Assessed Needs, Goals, Objectives, and Interventions

1. To add a new assessed need not listed - click Add; click in the priority field to give the need a priority number; add the Assessed Need; add a status and date identified. Add rationale if appropriate; click Save and close.
2. To prioritize the assessed needs in the grid if needed - click on the assessed need in the grid and click edit and change the priority number for that assessed need. To remove an assessed need, click on the assessed need in the grid and click remove. 

Goal, Objective and Intervention

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. (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.
17. Repeat the steps above to create several goals for each assessed need. 
18. Click the filter options to see the goals/objectives for 'Program' (if the client is enrolled in more than one program and if this is at an update/annual visit). 

Additional Services/Discharge

1. Click in the 'Additional Services' field and choose an item from the picklist (if applicable.) – Not Required
2. Click the 'Discharge plan' field and add a comment regarding the discharge plan discussed with the client.

Screening Tools

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.
3. Click on the 'Psychosocial Stressors link to open that window and document the information for that section (if applicable) click save and close to return to the template.

**Signature (Tasking Supervisor/Staff for review and signoff)

If you need a supervisor signature, click the 'Send Task' button, find your supervisor’s name in the 'Tasking Recipient' window, click your supervisor’s name in the list on the left, click the add button in the middle to add their name to the right side and click ok

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