1. Click the template icon and open the 'Packet Navigation' template from the list 
  2. Add the patient’s program to the program field 
  3. Click to open the 'Staffing Note' (BH) template from the Packet Navigation 

Staffing Details – Not Required – but beneficial

  1. Click in the radio button that best fit the reason for the staffing.
  2. Click in the 'Details' field and type the details regarding this staffing. 
  3. Skip the 'Support Resources' section unless the person listed was present for this staffing (not very common for adult staffing's and not used for internal staff attendees) 
  4. Click in the 'New Issues Identified' field and enter what was discussed by each person. that is participating in this discussion regarding the client's treatment. 
  5. Click in the 'Recommended Plans' field and type the recommended plan. Click in the 'Responsible Party' field type the name of the person that is responsible for the recommended plan and click the add button. 

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.
  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.

 

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  1. Click on the 'WHO Disability Assessment Schedule 2.0' link to open that template.

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  1. Click in the radio button that best answers each question, click save and close to return to the template.

 

Signature (Provider Signoff)

  1. Each Participant will add their own name in this section.
    1. Click in the box above the 'type' field and select provider from the picklist popup so your name appears in the boxes; add your title to the title field and click add so your name drops into the grid.

Billing

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

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  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

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