General 


  1. Click in the 'Date of admission' field and choose the date from the calendar popup
  2. Click in the 'Date plan written' field and choose the date from the calendar popup
  3. Click in the 'Revision date' field and choose the date from the calendar popup

Early Warning Signs

  1. Add a few checkmarks in each section and confirm the information appears in the summary for the document field. 
  2. Add a few comments in the comment field. 

Stress Contributors

  1. Add a checkmark to a few of the items in this section and confirm the information appears in the summary for the document field. 
  2. Add a few comments in the comment field. 
  3. Add a checkmark to a few of the items in the "What steps or actions can you take when you have to deal with these people, places, and things?' section. Confirm the information appears in the summary for the document field. 

Managing Stress 

  1. Add a checkmark to a few of the items in this section and confirm the information appears in the summary for the document field. 
  2. Add a few comments in the comment field. 
  3. Click the 'Add' button to open the support resources window
  4. Add a new support resource by completing the necessary sections; click save and close to return to the template. 
  5. Did the new support resource appear in the grid? 
  6. Click a few items in the 'Additional resources' and confirm your entries appear in the summary for the document section 
  7. Add comments in the comment field
  8. Add a checkmark to a few of the items in the 'Helpful Things People Can Do' section. Confirm the information appears in the summary for the document section. 
  9. Add a checkmark to a few items in the 'Helpful Things People Can Do' section and confirm the information appears in the summary for document field. 
  10. Enter comments in the comment field 
  11. Click 'yes' or 'no' to answer the question 'Is there anything else you would like to add to the Relapse Prevention Plan?' 
  12. Enter comments in the 'If Yes, add additional feedback' field 

Crisis Arrangements 

  1. Add a checkmark to a few of the items in the 'What should be done if you are in crisis?' section. Confirm the information appears in the summary for the document field. 
  2. Add a few comments in the comment field. 
  3. Enter comments in the 'What should NOT be done if you are in a crisis? Section. 
  4. Enter comments in the 'Medications that are helping or have helped in the past' section.
  5. Enter comments in the 'Medications that have NOT helped' section.
  6. Click 'yes' or 'no' to answer the question 'Is there anything else you would like to add to the crisis arrangements?' If you answer yes, enter comments.

 

Emergency Assistance 

  1. Click in the 'Contact Name' field and enter a contact name, click in the 'Phone' field and enter a phone number and click in the 'Area(s) of Assistance field and enter information. 
  2. Click the 'add' button to add the information in the grid provided. 

Advance Directives

  1. Click 'save and close' to return to the template
  2. Click 'yes' or 'no' to each question in this panel

 

 

Participant Acknowledgment

  1. Click 'yes' or 'no' to answer the question if the patient was provided a copy of the plan. 
  2. Enter comments if the patient does not receive a copy.

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.

 

 

 

Charges

 

  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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