Southern Indian Health Council

1. Open any patients chart that is in the group to begin documentation 
2. Click on the 'Group Encounter' (encounter w/faces on it)
3. Click the 'Template' icon to open the list of templates 
4. If the 'Group Prog Note' (BH) is not visible, click the all radio button. Click on the 'Group Prog 

Group Information

            Don't forget to do the 4 point check and confirm this is the correct patient’s chart. 

*The information added in this panel will appear for all members of this group.

1. Click in the 'Name of Group' field and choose the name of the group and click ok. 
2. Click in the 'Duration' field and choose the duration of the group and click ok.
3. Click in the 'Number of Attendees' and enter the number of attendees in the group and click ok. 
   1. If the group was offsite add a checkmark to the field box and enter the location in the comment box. 
4. Add the 'Facilitator's names in the fields when there is more than one. 
5. Click in the field box next to the 'Teaching Methods' for this group (you can choose more than one) 
6. Click in the 'Skill-building/understanding' field box and choose from the picklist provided.
7. Click in the 'Attentiveness/participation' field box and choose from the picklist provided. 
8. Click in the 'Name of problem/need addressed in group' and enter the discussion during group. 

Individual's General Group Participation 

Information entered in the next few panels is regarding the individual’s participation in the group. 

1. Click the radio button that best fits if the individual was present or not present for the group.
2. Click the radio button that best fits the individual’s behavior during group.
3. Click the radio button that best fits the individual’s mood during group.

New Issues 

1. Click the radio button that best fits if new issues were discussed during group or not.
2. Click in the 'Explanation' field and enter an explanation regarding the new issue or no new issue.

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 picklist provided of any goals that were discussed with the client during this visit (filter the goals if needed by the program.)
2. Click in the 'comment' field and click add so it appears in the grid. 
3. Repeat the steps above if there is more than one goal being discussed in this visit. 
4. Click in the 'Interventions/methods provided' field and enter the interventions addressed today. 
5. Click the 'Response to intervention/progress toward goals and objectives and enter the responses toward the goals and objectives discussed. 

Plan/Additional Information/Discussion

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