Clinical Profile updates

Profile version updates

Version 5.7.0 December 5, 2024

Portal updates

  • Added "Employer" and "Job Title" to the "Additional Demographics" section of the online Portal Application.
    • These fields will import to the "Edit Client" screen.

Assessment updates

In the "Medical History" section of the *Pre-Screen/IA:

  • Updated the display of Meds Tab medications so that only active medications appear.

In all "Mental Status Exam" sections:

  • Updated "Mood" subsection to include more options.
  • Moved  the following checkbox options from "Mood" to "Affect" section:
    • Euthymic, euphoric, expansive, labile.
  • Removed "As evidenced by:" label from all MSE subsections.


In the "Emotional/Behavioral" section of the *CDA/BPS and **CDA/BPS:

  • Added specific fields for "Sexual Preference" and "Sexual Orientation."

In all "Risk Assessment" sections:

  • Removed the dependency value for the provider facing prompt text.
    • "If Risk is Moderate or High, complete Safety Plan. (i.e. further assessment, appropriate phone calls, referrals, etc.)" red prompt language will now display even if "Safety Plan Indicated" is not selected.

Template updates

  • Added "*Non-Disclosable Psychotherapy Note."


Group Note Updates

In the *Group Therapy template:

  • Corrected a typo in the spelling of "Initial Diagnosis."

Version 5.6.0 November 3, 2023

Assessment updates

In all "Additional Demographics" sections:

  • Removed "Preferred Language" and "Marital Status" as they are now included in the "Demographics" section.
  • Added "Do you have any special communication needs (e.g. sign language)."

In all "Presenting Condition/HPI" sections:

  • Updated the red provider facing prompt text to: "Reflect the client's own words and verbatim explanation as to why they are here for help, (covering their presenting needs/issues/problems.) When applicable and permitted, relevant information from family (significant others) and other collateral sources. Address precipitating factors; current circumstances of living; and your sources of information."

In all "Medical History" sections:

  • Changed "Primary Care Physician" to: "Primary Health Care Provider" and removed the field for "Last Name" to allow for the name of a facility to be entered.
  • Under "Medical Conditions", added additional follow-up checkboxes which display when "Acute/Chronic Pain" is selected.
    • Pain Assessment Indicated
      • Supplemental Tool/Assessment Used (populates additional Prompt Text to the "Supplemental Assessment Tools / Records" section).
      • Referral Needed (populates additional Prompt Text to the "Initial Treatment Plan" section Referrals Needed/Provided subsection).

  • Under "Medical / Surgical Treatment History":
    • Updated the red provider facing prompt text to: "Include any recent emergency care and alternative/complementary treatment(s)."
    • Changed "Medical Condition" to "Procedure / Medical Condition."
  • Revamped the Nutrition Section:
    • Added "(including special dietary needs and restrictions associated with medication use)" to "On a Special Diet."
    • Added additional follow-up checkboxes for "Eating Habits or Behaviors that may be Indicators of an Eating Disorder":
      • Bingeing
      • Inducing Vomiting
      • Excessive Restriction/Avoidance of Food
      • Frequent Use of Laxatives
      • Ingestion of Non-Food
    • Added "Nutrition Assessment Indicated" with two follow-up checkboxes:
      • "Supplemental Tool/Assessment Used" (populates additional Prompt Text to the "Supplemental Assessment Tools / Records" section).
      • "Referral Needed" (populates additional Prompt Text to the "Initial Treatment Plan" Referrals Needed/Provided subsection). 
    • Added "None Reported" to the Nutrition Subsection in the "**CDA/BPS."
  • Moved "Family Medical History" to the end of the "Medical History" section.

In all "Substance Use & Withdrawal Potential" sections:

  • Re-ordered content for a more natural flow:
    • "IV Drug Use", "Have you ever shared needles", and "Any instances of Overdose" moved directly below the "Substance Use" table. 
    • "Active Withdrawal Symptoms Reported or Observed" are now hidden by default unless checked.
    • If "Supplemental Assessment Used (i.e. COWS, CIWA)" is checked, additional prompt text appears in the "Supplemental Assessment Tools / Records" section: "COWS/ CIWA Used (Record details below)."
    • "Impact of Substance Use/Addiction on Daily Living" moved directly below "Active Withdrawal Symptoms."
    • "Previous Diagnoses" moved to the bottom of the section, directly above "Family History of Mental Health, Substance Use, Gambling, or Other Addictive Behaviors."

In the "Behavioral Health / Substance Use History" section of the "*Pre-Screen/IA":

  • Updated the "Legal Needs or Considerations" label to: "Legal Needs or Considerations: (Arrests, Court appearances, Fines, Separation/divorce, Loss of custody, Incarceration)."
  • Updated the "Trauma, Abuse, Neglect, Exploitation" label to: "Trauma, Abuse, Neglect, Exploitation: (Please describe any incidences where you have been a victim, perpetrator or witness of current or past trauma, physical abuse, sexual assault, neglect, domestic or neighborhood violence, sexual or any other type of exploitation, or other adverse life experiences)."

In the "Emotional / Behavioral" section of the "CDA/BPS":

  • Updated the red provider facing prompt text of "Trauma, Abuse, Neglect, Exploitation" to: "Explain client's experience (as victim, perpetrator, or witness) of trauma, abuse, neglect, or exploitation, physical abuse, sexual assault, neglect, domestic or neighborhood violence, sexual or any other type of exploitation, or other adverse life experiences). Abuse, neglect, and exploitation must be reported to authorities per law and regulation, and documented. Consider client's exposure, intrusion, avoidance, negative alterations in cognition/mood, arousal, reactivity, dissociative symptoms?"

In the "Recovery / Living Environment" section of the "CDA/BPS":

  •  Updated red provider facing prompt text:
    • Under "Family History", added: "including divorce, bereavement, incarceration of significant other."
    • Under "Basic Living Skills / Functional Deficits", added: "Food Insecurity?"
    • Under "Vocational/Employment Needs or Considerations", added: "Include brief employment history."
    • Under "Financial Needs or Considerations", added: "Include any difficulty accessing and/or paying for health care and/or medications."
    • Under "Educational Needs or Considerations", added: "Include brief educational background/history and literacy levels."
    • Under "Legal Needs or Considerations", added: "Include Arrests, Court appearances, Fines, Separation/divorce, Loss of custody, Incarceration."
    • Under "Cultural Considerations", added: "Include preferences and any variables that may impact treatment."
    • Under "Religion / Spiritual Orientation", added: "Include any beliefs or variables that may impact treatment."

In all "Strengths, Needs, Abilities and Preferences" sections:

  • Updated red provider facing prompt text to: "In the client's words: strengths, needs, abilities, and treatment preferences, e.g., time availability and barriers to treatment, gender of counselor, leisure time/recreational activities, spiritual activities, individual or group therapy, medication, time availability."

In all "Supplemental Assessment Tools / Records" sections:

  • Updated red provider facing prompt text to: "Please include any ancillary resource(s) having bearing on your Provider Interpretive Summary and Clinical Formulary. e.g. Scales/Measurements (CSSRS-Triage, LEC-5, PHQ-9), Assessments, Level of Care Criteria's, Consultation Reports, etc."
  • Added reminder prompt text which will appear if indicated for:
    • COWS/ CIWA Used (Record details below)
    • Pain Assessment Used (Record details below) 
    • Nutrition Assessment Used (Record details below) 
  • Added new "Completed By" column to the "Supplemental Assessment Tools / Records" table.
  • The "Supplemental Assessment Tools / Records" table is now mirrored with population between assessments.

In the "Clinical Formulation & Medical Necessity" section of the "*CDA/BPS":

  • Updated the "Recommended Level of Care" drop-down for "Formulation by LOCUS" to include "CALOCUS Levels of Care."
  • Updated the "Clinical Formulary of Client's Needs and Severity of Risk" label so that it now reads: "Provider Interpretive Summary and Clinical Formulary of Client's Needs and Severity of Risk."
  • Updated the red provider facing prompt text to: "Based on the assessment data, detail the individual's relevant clinical history and the biological, psychological, and social factors including co-occurring disabilities, comorbidities, and/or disorders indicating clinically significant distress or impairment in social, occupational, or other important areas of functioning."

In all "Initial Treatment Plan" sections:

  • Added new red provider facing prompt text under "Initial Goal(s)": "Record Client Stated Goal(s), e.g., 'What is the most important thing you'd like to accomplish during treatment?'."
  • Updated the "Case Management" recommended service to "Case Management/PRP."
  • Added prompt text under "Referral(s) Needed/Provided" to include "Pain Assessment" and "Nutrition Assessment" if indicated in the "Medical History" section.
  • Added new "Referral Type" column to the "Referral(s) Needed/Provided" table with options for "In-House" and "External."
  • The "Referral(s) Needed/Provided" table is now mirrored and will populate between assessments.

Treatment Plan Updates

In the "Discharge/Transition/Aftercare Plan(ning)" sections:

  • Added "Anticipated Referrals" label to the "*MTP."
  • Added "Referrals" label to the "*DS/Transition."

Version 5.0.0 June 20, 2023

Portal Updates

The Portal Application now allows for the inclusion of a limited set of pre-defined variables enabled upon request. The text label prompt for Variable 2 is the only element that can be uniquely determined by your company..

The available variables are as follows:

  • Portal Variables 1 and 2:

  • Portal Variable 3:

  • Portal Variable 4:

Assessment updates

In all "Additional Demographics" sections:

  • Removed the word "Attained" from "Highest Level of Education Attained" to allow for a larger text response.
  • Corrected "Difficulty Reading or Writing" text area not populating in some cases.

In the "Medical History" section of the "*Pre-Screen/IA":

  • Added codes to pull Medications and Allergies from the "Meds" and "Allergies" tabs respectively to eliminate redundancy when the "*Pre-Screen/IA" is not completed via the Client Portal.
  • Corrected "Reviewed Past Medications" checkbox and accompanying text area not populating in some cases.
  • Corrected COVID-19 "Not Vaccinated" checkbox not populating in some cases.

In all "Substance Use & Withdrawal Potential" sections:

  • All "Active Withdrawal Symptoms" text areas now align right for a cleaner look.

In the "Recovery / Living Environment (Social Determinants of Health)" section of the "*CDA/BPS":

  • For each domain, the text areas will now display automatically and are no longer dependent on a checkbox. Screening for each domain within this section is required for auditing and accreditation. The checkboxes falsely created an impression that the elements could be skipped.

In the "Emotional / Behavioral" section of the "*CDA/BPS":

  • Resolved "(Symptom onset, frequency, & duration)" red provider prompt text displaying on snapshot and moved to a new line.
  • Removed indentation on all text areas to align with standard formatting.

In "Readiness to Change/Stage of Change" section of the "*CDA/BPS":

To clarify that this section is co-occurring content:

  • Updated section label from "Readiness to Change" to "Readiness to Change/Stage of Change." 
  • Removed the phrase "in recovery" from the red provider prompt text.

In the "Clinical Formulation & Medical Necessity" section of the "*CDA/BPS":

  • Moved "Provider Summary and Clinical Formulary of Client's Needs and Severity of Risk" label and accompanying red provider prompt text below the "Select Formulation" options to reduce confusion (see Figure 13-1).
  • For "Formulation by LOCUS": Changed "Dimension" to "Parameter" in accordance with AACP (see Figure 13-1).
  • Split "Parameter IV" into "Parameter IV.A - Recovery Environment (Level of Stress)" and "Parameter IV.B - Recovery Environment (Level of Support)" (see Figure 13-1).

Figure 13-1. "LOCUS Formulation."

In all "Medical Review of Systems" sections:

  • Aligned checkboxes in the "Genitourinary / Urology" subsection for a cleaner look.

In the "Social History" sections of the "*Psych Eval" and "*H&P Exam":

  • Corrected a grammatical error in the red provider prompt text.

In all "Initial Treatment Plan" sections:

  • Shortened the text area for "Drug Testing Rationale" to avoid a wrapping issue.

In the "Family" section of the "*CM ASMT & Plan":

  • Corrected a grammatical error.

In the "Discharge/Transition Summary":

  • Updated titling from "Discharge" to "Discharge/Transition."
  • Moved "Reason for Discharge/Transition" to come after "Levels of Care."
  • Reordered the section "Inactive Problem List" to come directly after "Active Problem List."

Version 4.9.0 January 17, 2023

Assessment updates

In all "Additional Demographics" sections:

  • Updated "Preferred Language" drop-down select box to match the Edit Client FHIR list.

In all "Initial Treatment Plan" sections:

  • Added "Wellness Plan" to "Recommended Services."
  • Added "Safety Plan" to "Recommended Services."
  • Changed "Recovery Services" to: "Peer Support / Recovery Coaching Services."
  • Removed "Community-Based Support."
  • Set all checkboxes to display on snapshot.

Template updates

In all Progress Notes:

  • Updated the "Session Details" AutoNote™ to include remote/telehealth options of "Remote/Telehealth-In home" and "Remote/Telehealth-Out of Home."

In the "*Tx- Progress Note, Medical" and the "*Tx- Progress Note, Psychiatric":

  • Updated the "NA_PN_MED_ROS_ATP (Medical ROS)" AutoNote™ to allow users to both report and deny items without needing to "Append Multiple" (see Figure 12-1).

Figure 12-1. "NA_PN_MED_ROS_ATP (Medical ROS)."

Version 4.8.0 July 25, 2022

Assessment updates

*The "*Nursing Assessment" has been retitled "Medical Assessment" to broaden the scope. The same change was made for the associated "*Tx- Progress Note, Nursing" and "*Tx- Chart Note, Nursing."


In all "Medical History" sections:

  • Reprogrammed all medical condition checkboxes to stay visible on snapshot even if not checked.
  • Converted "Current and/or Past Medical Conditions" details from a static label and textbox to a checkbox and dependent textbox. 
  • Converted "Nutritional Details / Comments" from a static label and textbox to a checkbox and dependent textbox.

In all "Substance Use History" sections:

  • Combined "Age of 1st Use" & "Age Became a Problem" into one column and reinstated a column for "Symptoms, Withdrawal, Cravings, Increased Tolerance" (see Figure 11-5).
  • Reinstated Method/Means of Acquisition Table (see Figure 11-5).
  • Changed "Family Mental Health / Substance Use History" to "Family History of Mental Health, Substance Use, Gambling, or Other Addictive Behaviors."
  • Changed "Longest Period of Sobriety and Anything That Helped You Accomplish That Time" to "...Recovery/Sobriety."

Figure 11-5. "New column and table in Substance Use & Withdrawal Potential."

In all "Mental Status Exam" sections:

  • Reprogrammed all checkboxes to stay visible on snapshot even if not checked.

In all "Risk Assessment" sections:

  • Made "Imminent Danger" a separate selectable option (see Figure 11-4).

Figure 11-4. "Imminent Danger in Risk Assessment."

In the "Additional Demographics" section of the "*Pre-Screen" and "*CDA/BPS":

  • Updated options in the "Preferred Language" drop-down.

In the "Clinical Formulation & Medical Necessity" section of the "*CDA/BPS":

  • Added new "Formulation by LOCUS" option (see Figure 11-3).
  • Changed the title of "Dimension 1" in the "Formulation by Dimension" to "Dimension 1: Acute Intoxication and/or Withdrawal Potential."

Figure 11-3. "Formulation by LOCUS."

In the "Emotional / Behavioral" section of the "*CDA/BPS":

  • Replaced "Shopping?" with "Other Process Addictions?" in the red text for "Other Addictive or Compulsive Behaviors."

In the "Recovery / Living Environment" section of the "*CDA/BPS":

  • Added "Meaning, Purpose, and Values."

In the "Physical Exam" section of the "*H & P Exam":

  • Removed "Neck" as it was redundant to "HEENT" and removed "Rectal" due to lack of relevance.

In the "Master Treatment Plan":

  • Removed the "Strengths, Needs, Abilities, and Preferences" population from the "Case Management Assessment & Plan" due to redundant display.
  • Reworked the "Acknowledgements" labeling.

In the "Case Management Assessment & Plan":

  • Typo corrections.

Template updates

In all "Progress Notes":

  • Reprogrammed the "Data" AutoNote™ to only pull in active objectives from the Treatment Plan.
  • Removed "Missed Appointment" from the "Session Details" AutoNote™.

In the "*Tx- Progress Note, Clinical":

  • Split the "Data" AutoNote™ into two buttons for the visual ease of providers.

In the "*Tx- Progress Note, Psychiatric":

  • Added "Session Type" options to the "Session Details" AutoNote™ to include "with Medication Review" and "without Medication Review."

In the "Assessment" AutoNote™ of the "*Tx- Progress Note, CM" template:

  • Changed "Progress toward goals & ongoing assessment of capacity to independently access services" from a prompt label to an independent text area to ensure completion.

Version 4.7.0 January 18, 2022

Assessment updates

In the "Insurance Information" section of the "Portal / Pre-Screen":

  • Re-ordered text fields for a more logical flow and added "Policyholder DOB" (see Figure 10-7).

Figure 10-7. "Insurance Information."

In all "Medical History" sections:

  • Added COVID-19 "Booster" text box and "Not Vaccinated" checkbox (see Figure 10-1).

Figure 10-1. COVID-19 "Booster" text box and "Not Vaccinated" checkbox.

In the "Substance Use History" sections:

  • Changed "How are these substances acquired" to "Are you encountering any degree of risk when you are acquiring substances" with "Please describe, if comfortable" text area (see Figure 10-2).

  • Added a previous diagnoses question and a previous diagnosis table (see Figure 10-3).

Figure 10-2. Updated "How are these substances acquired."

Figure 10-3. Previous Mental Health or Substance Use Diagnoses.

In the "Recovery / Living Environment" section of the "CDA/BPS":

  • Added "(SDOH) Social Determinants of Health" label and definition.
  • Added "Other (SDOH) Social Determinant of Health" option (see Figure 10-4).

  • Moved question "Are there any persons or situations that pose a threat to the clients safety or participation in treatment" from the "Recovery/Living Environment" section into the "Risk Assessment" section.

Figure 10-4. Social Determinants of Health prompt text.

In the "Clinical Formulation & Medical Necessity" section of the "CDA/BPS":

  • Added clarification labeling (see Figure 10-5).

Figure 10-5. "Clinical Formulation & Medical Necessity" clarification labeling.

In all "Initial Treatment Plan" sections:

  • Added "Need for Assistive Technology" checkbox and text box (see Figure 10-6).

Figure 10-6. "Need for Assistive Technology" checkbox.

In the "Case Management Assessment & Plan":

  • Programmed "Strengths, Needs, Abilities, & Preferences" to auto populate from the "CDA", for those on the "Acuity Set", this populates from the "**NA."
  • Changed the drop-down language from "Independently" to "Completely Independent."

Version 4.6.0 August 26, 2021

Assessment updates

*New Med/Clinical Case Management Assessment & Discharge Summary with supporting Treatment Plan Library Content is now available upon request. 


These documents were designed in accordance with UnitedHealth (Optum) standards and guidelines for Case Management, and feature:

  • Nine standard Case Management domains with selectable options for the client's intensity of need and the prioritization of those needs (see Figure 9-1).
  • A "Treatment Planning and Review" section that works in tandem with the new Case Management specific Treatment Plan Library content (see Figure 9-2).
  • A "Summary of Referral/Collaboration" section designed specifically for Case Management referral activities (see Figure 9-3).
  • Includes an associated standalone "Case Management Discharge Summary."

Figure 9-1. Example of completed Case Management Domain.

Figure 9-2. "Treatment Planning and Review" section of new "Case Management Needs Assessment."

Figure 9-3. "Summary of Referral/Collaboration" section of the new "Case Management Needs Assessment."

In the "Medical History" sections:

  • Added a checkbox to indicate COVID-19 Vaccination and added Vision and Hearing Impairment to Medical Conditions (see Figure 9-4).

Figure 9-4. COVID-19 and new Medical Conditions.

In the "Substance Use History" sections:

  • The column for "Withdrawal, Cravings, Increased Tolerance" in the Substance Use History Table has been removed as it is addressed when selecting the appropriate diagnostic criteria for substance use diagnoses.
  • Added "Pattern Of Use" options to the Substance Use History Table with a follow-up text area for how substances are being acquired, replacing the need for an additional table (see Figure 9-5).

 

Figure 9-5. Substance Use History Table.

In the "Formulation by Dimension" section of the "Clinical Formulation and Medical Necessity" in the "CDA/BPS", added the following levels of care:

  • Level 1- Ambulatory Withdrawal Management w/o Extended On-Site Monitoring.
  • Level 2- Ambulatory Withdrawal Management w/ Extended On-Site Monitoring.
  • Level 3- Residential/Inpatient Withdrawal Management.
  • Level 3.2- Clinically Managed Residential Withdrawal Management.

In the "Discharge Summary":

  • The population coding was updated for "Presenting Condition", "Strengths, Needs, Abilities, and Preferences", and "Treatment Planning Participation by Family or Significant Others." It is now coded to mirror data from the Master Treatment Plan in order to correct inconsistent population.

Template updates

Diagnosis Population in all Progress Notes:

  • Previously, a client's diagnosis was hardcoded to auto-populate from the Master Treatment Plan directly into the body of the note.
  • Now, client diagnoses (Initial and Master) are available for provider selection via AutoNote™ buttons shown below (PN_CL_DIAGNOSIS_ATP) (see Figure 9-6).

Figure 9-6. Progress Note Diagnosis Selections.

Group Note Updates

In the "*Drug UA Results" Group Note:

  • Added the client's date of birth.
  • Changed the label from "BAC (Blood Alcohol Content)" to "ALC (Alcohol)" and added the standard result selectable options.

In the "*Group Therapy" Group Note:

  • Added Initial Diagnosis (see Figure 9-7).

Figure 9-7. Group Note Diagnoses.

Portal Updates

  • Changed the label for "Sex" to "Sex at Birth."
  • Added a prompt label to "First Related Contact" to read. "Please be sure to indicate at least one emergency contact."

Version 4.5.0 March 24, 2021

Assessment updates

In the "Mental Status Evaluation" section of the "CDA/BPS", "Nursing Assessment", and "Psychiatric Assessment":

  • Changed the "Thought Content & Perception" subsection to clearly contain three subsections for "Thought Content", "Perception", and "Thought Process" (see Figure 8-3).

Figure 8-3. Mental Status Evaluation.


In the "Risk Assessment" section of the "CDA/BPS", "Nursing Assessment", and "Psychiatric Evaluation":

  • Per recommendation from The Joint Commission, added an area for overall risk level selection and narration.

In the "Psychiatric Review of Systems" section of the "Psychiatric Evaluation":

  • Added "Issues with" in front of the symptomology labels ("Sleep" through "Anxiety/Panic Attacks").

In the "Discharge Summary":

  • Replaced the "Summary of Progress" section with BestNotes' standard "Problem Detail" section (as seen in the "Master Treatment Plan"), allowing population and full visibility of itemized "Reviewed/Updated" data that is recorded in the "Master Treatment Plan" at the time of "Treatment Plan Review." This allows for seamless inclusion of discipline specific treatment plans.

In the "*Pre-Screen" Assessment:

  • Changed the title from "*Pre-Screen Assessment" to "*Pre-Screen / Intake Assessment."

Template updates

In the "*Tx- Progress Note, Clinical DAP" and "*Tx- Progress Note, Clinical SOAP" templates:

  • Added the "Session Details" AutoNote™ series.

In the "*Tx Progress Note- Psychiatric" template:

  • Added code for the last recorded vitals to auto-populate and be displayed.

In the "*Tx Progress Note- Nursing" template:

  • Added "Fatigue", "Weakness", and "Poor Appetite" to the "General, Constitutional" AutoNote™.
  • Added "Insomnia" to the "Neurological" AutoNote™.

Group Note updates

In the "*Group Therapy" note:

  • Added "Provider Location" selectable options of "Telehealth", "Office", and "Community."
  • Added Client "Location" selectable options of "Telehealth", and "In-person."

In the "ATP G- Session Summary Report" (*Group Therapy Associated Report):

  • Added "Provider Location" and Client "Location" to displayed data points.

Version 4.0.0 February 9, 2021

Group Note updates

In the "*G- Group Therapy" note:

  • Added 30, 90, and 240 minute time options to the "Total" drop-down list.

Template updates

In the "*Tx- ASAM LOC Criteria" template:

  • Created a new "ADOLESCENT_LOC" AutoNote™ series which contains ASAM Level of Care criteria for adolescents.
"*Tx- ASAM LOC Criteria" template available by request only

Version 3.8.0 December 18, 2020

Assessment updates

  • Formatting clean up for snapshot and print views.

In the "Insurance Information & Additional Demographics" sections:

  • In accordance with CARF 2.B.13.q. added "Do you have any difficulty reading or writing" with a follow up "Please explain" if indicated.

In the "Medical History" sections:

  • Per request of UnitedHealth (Optum), changed "Client reported no known allergies." to "Client reported no known drug, food, or environmental allergies."
  • In the "Medical Conditions" subsection: If pregnancy is indicated, added a follow up checkbox "Receiving Prenatal Care" and a text box for "Provider."

In the "Substance Use History" sections:

  • Per request of UnitedHealth (Optum), changed the prompt language of "Family Mental Health/Substance Use History" to "Include any history of treatment, if applicable, or note an absence of treatment, as well as the overall impact on client."

In the "Mental Status Exam" sections:

  • Added "Congruent" and "Incongruent" to the Affect section.

In the "Emotional / Behavioral" section of the "Comprehensive Diagnostic Assessment/Biopsychosocial":

  • Due to clarification from UnitedHealth (Optum), edited prompt text to read "Required for youth under 18. Include history of sexualization, victimization, witnessing and perpetration, patterns of adjustment/maladaption, sexual understanding and outlook, sexual preference and orientation, co-occurring issues."

Group Note updates

  • *Group Therapy: added the code to populate each client's individual billing data for the session after the note is "Saved & Locked." Added "See Below" as a default display option in the "Billing" field. Codes can still be entered into the "Billing" field if applicable.

Template updates

  • Adjusted spacing in all templates.
  • In accordance with UnitedHealth (Optum) guidelines for CBRS, changed the "Intervention & Education" options in the "PN_CBRS_DATA" "Data" Autonote™ to "Enhancing, Developing, Enhancing and developing, social skills, communication skills, behavior skills, coping skills, basic living skills."
  • Added "Homeless" as an option in the Risk button of the PN_ASSESSMENT_ATP Autonote™ series.

Version 3.7.0 October 5, 2020

Assessment updates

In the "Master Treatment Plan":

  • Moved "Discharge/Transition/Aftercare Planning" and "Crisis Plan" sections to display after the "Problem Details" section.
  • "Client Reported Stressors / Areas of Difficulty" code corrected to populate from the "*Comprehensive Diagnostic Assessment/Biopsychosocial."

Group Note updates

In the "*Drug UA Results Group Note":

  • Added new substances to panel, alphabetized, added "dilute" as a result option, associated library report also updated.

Progress Note updates

  • "*Psychiatric Progress Note" was re-designed to include "Medication Review", standard clinical data content, standard clinical assessment content, and "Lab Orders, Results, Testing."

Updated "Data" AutoNote™ as follows (see Figure 8-1):

  • Addressed in session options to include: "Goal", "Problem", and "Objective."
  • Added "Therapeutic Interventions Used in Session", "Response", "Readiness to Change", "Current Functioning", "Treatment Plan Progress" from "Risk and Response" AutoNote™ into the "Data" AutoNote™ from the "Response/Risk" AutoNote™.

Updated the "Response/Risk" button within the "Assessment" AutoNote™ series as follows: (see Figure 8-2)

  • Re-titled to "Risk."
  • Moved "Therapeutic Interventions used in Session", "Response", "Readiness to Change", "Current Functioning", "Treatment Plan Progress" from "Risk and Response" into the "Data" AutoNote™.
  • Changed the label Risk Assessment" to "High Risk Behavior" for clarity.
  • Moved "Level of Care Status" button into the "Assessment" AutoNote™ series (see Figure 8-3).

Progress Notes Effected: Clinical, Clinical DAP, Clinical SOAP, Psychiatric, and Utilization Review.

Figure 8-1. "Data" AutoNote™.

Figure 8-2. "Risk" AutoNote™.

Figure 8-3. "Level of Care Status" new location.

Full mock-up of redesigned progress note (see Figure 8-4):


Figure 8-4. Completed progress note.

Version 3.6.0 September 03, 2020

Assessment updates

In the "Medical History" sections:

  • Added a "Notes/Comments" text-box for both medications and allergies.
  • Fixed a population error that prevented the "Eating Habits or Behaviors that may be Indicators of an Eating Disorder, such as Bingeing or Inducing Vomiting" checkbox from populating correctly.

In the "Substance Use History" sections of the "Comprehensive Diagnostic Assessment/Biopsychosocial", "Nursing Assessment", and "Psychiatric Evaluation":

  • Added a "Supplemental Assessment Used (i.e. COWS, CIWA)" checkbox to "Active Withdrawal Symptoms."
  • Removed the bold font style from the "Active Withdrawal Symptoms" checklist.

In the "Presenting Condition/HPI" section of the "Nursing Assessment":

  • Added "Client Reported Stressors/ Areas of Difficulty", which populates to the Master Treatment Plan.

In the "Initial Treatment Plan" section of the "Nursing Assessment":

  • Fixed a population error that caused this section to populate from the "Comprehensive Diagnostic Assessment/Biopsychosocial."

Version 3.5.0 August 19, 2020

Assessment updates

  • Removed the "History of Present Illness" section from all assessments.
  • Re-titled the "Chief Complaint" section to "Presenting Condition/HPI" in all assessments.

Version 3.4.0 July 1, 2020

Progress note updates

Formatting updates for the following AutoNotes™:

  • NA_PN_MED_REVIEW_ATP
  • MENTAL_STATUS_ATP
  • ASAM_LOC_CRITRIA_ATP
  • PN_CM_ASMT_ATP

Assessment updates

  • Changed the title of the "CDA" to "CDA/BPS" on the navigation tab and "Comprehensive Diagnostic Assessment/Biopsychosocial" within the assessment.

In the "Substance Use History" sections:

  • Added a table which indicates "Pattern of Use" and "Method of Acquisition" in accordance with The Joint Commission CTS.02.03.07 #1.
  • Added "History of Physical Problems Associated with Substance Abuse, Dependence (Indicate "None" if not Applicable)" in accordance with The Joint Commission CTS.02.03.07 #2.
  • Added "Relapse History" in accordance with The Joint Commission CTS.02.03.07 #7 (see Figure 7-1).

Figure 7-1. "Substance Use History" additions.

In the "Initial Treatment Plan" sections:

  • Added "Drug Test" checkbox and "Rationale Required" follow up text box in accordance with The Joint Commission CTS.02.03.15 #2.

In the "Emotional / Behavioral" section of the "Comprehensive Diagnostic Assessment":

  • Added "Include any associated physical problems" to the red text prompt under "Other Addictive or Compulsive Behaviors (Non-Substance Use)" in accordance with The Joint Commission CTS.02.03.07 #1.

In the "Recovery / Living Environment" section of the "Comprehensive Diagnostic Assessment":

  • Added red text prompt to "Housing Needs or Considerations", "Describe client's current living arrangements and environment and options for an alternative, supportive living environment" in accordance with The Joint Commission CTS.02.03.07 #2.
  • Added "Include client's perception of the role their spirituality or religion plays in their life and recovery" to the red text prompt under "Religion / Spiritual Orientation" in accordance with The Joint Commission CTS.02.03.07 #2. 

Treatment plan updates

In the "Master Treatment Plan":

  • Added the "Treatment Planning Participation by Family or Significant Others" section which populates from the "Recovery / Living Environment" section of the "Comprehensive Diagnostic Assessment."

In the "Discharge Summary":

  • Added the "Treatment Planning Participation by Family or Significant Others" section which populates from the "Recovery / Living Environment" section of the "Comprehensive Diagnostic Assessment."
  • Added a prompt to the "Prognosis and Recommendations" section, "Include contingency recommendations and guidance if a return to treatment is needed" in accordance with The Joint Commission CTS.06.02.01 #4.

Version 3.3.0 May 8, 2020

Progress note updates

In the "Response/Risk" AutoNote™, combined "Current Functioning" with "Strengths and Challenges" (see Figure 5-2).

Figure 5-2. "Response/Risk" AutoNote™.

Assessment updates

  • In the "Medical History" sections, included food allergies in the red prompt text for "Nutritional Details/Comments" per The Joint Commission surveyor request.
  • In the "Medical History" sections, added a checkbox to indicate review of past medications.
  • In the "Substance Use History" sections, updated the red text prompt for "Impact of Substance Use/Addiction on Daily Living" and removed three redundant questions.
  • In the "Substance Use History" sections, changed the formatting of the "IV drug use" questions.
  • Added "Military History" to the Portal, Pre-Screen, and CDA.

Portal / Pre-Screen updates

Added three columns to the medication table: "Start Date", "Stop Date", and "Effective" (see Figure 5-1).

Figure 5-1. Medication table.
  • Added "Gender Identity" and "Preferred Pronoun" selections.
  • Added "Legal."
  • In the "Medical History" section, re-titled checkbox to "No current/past prescriptions or over the counter medications."
  • Added "Trauma, Abuse, Neglect and Exploitation" in accordance with The Joint Commission CTS.02.02.05.
  • Re-titled "Insurance ID" to "Member ID" and added "Group ID" to the "Insurance Information."
  • In the "Substance Use History" section, added follow up questions and coded to populate to the "Substance Use History" sections in all other assessments.
  • Changed formatting and added client facing prompts to the "Behavioral Health History" section.

Version 3.2.0 March 20, 2020

Progress note updates

Added a "Telehealth", "Location" option to the "Session Details" of progress notes (see Figure 3-6).

Figure 3-6. "Telehealth", "Location" option.

Added selectable options for "Readiness to Change" in the "Response/Risk" AutoNote™ in progress notes (see Figure 3-5).

Figure 3-5. "Readiness to Change" options.

Assessment updates

Moved "Eating Habits" from the "Behavioral Health History" section in the "Comprehensive Diagnostic Assessment" to the "Medical History" section by the request of The Joint Commission surveyors. This content will display in the "Medical History" sections in the portal application and all assessments (see Figure 3-4).

Figure 3-4. "Eating Habits."

Psychiatric Assessment updates

Removed redundant "Family History" and "Limitations" sections. Removed "Prognosis" section as an unnecessary field.

Re-titled the "Assessment" section to "Clinical Impression and Summary" and added a red text prompt (see Figure 3-3).

Figure 3-3. "Clinical Impression and Summary."

Master Treatment Plan and Discharge Summary updates

Reformatted the "Discharge/Transition/Aftercare" section in the "Master Treatment Plan", and "Discharge Summary" for improved snapshot display (see Figure 3-2).

Figure 3-2. "Discharge/Transition/Aftercare."

Group note updates

Added "Next Appointment" to the "*Group Therapy Note." Added coding that will automatically reflect the date and start time from an associated calendar appointment. Minor adjustments for visual improvement (see Figure 3-1).

Figure 3-1. "*Group Therapy Note."

Version 3.1.0 January 23, 2020

Comprehensive Diagnostic Assessment updates

  • In accordance with CARF 2.B.13.(b)(c)(d)(e), re-titled "Strengths and Preferences" to "Strengths, Needs, Abilities and Preferences."

In the "Medical History" section:

  • Fixed an issue where the "None Reported" checkbox under "Medical Conditions" was not hiding on snapshot.
  • Added a spacer line between "Explain all Indicated Current and/or Past Medical Conditions" and "Medical/Surgical Treatment History."

Nursing Assessment updates

In the "Substance Use History" section:

  • Fixed an issue where the "Treatment History" table was not hiding when the "Client Denied Any Current and/or Past Behavioral Health Treatment" checkbox was selected.

Psychiatric Assessment updates

  • In accordance with CARF 2.B.13.(b)(c)(d)(e), re-titled "Strengths and Preferences" to "Strengths, Needs, Abilities and Preferences."

In the "Substance Use History" section:

  • Fixed an issue where the "Treatment History" table was not hiding when the "Client Denied Any Current and/or Past Behavioral Health Treatment" checkbox was selected.

Master Treatment Plan updates

  • In accordance with CARF 2.B.13.(b)(c)(d)(e), re-titled "Strengths and Preferences" to "Strengths, Needs, Abilities and Preferences."

In the "Strengths, Needs, Abilities and Preferences" section:

  • Programmed the current text-box to populate from the "Comprehensive Diagnostic Assessment."
  • Added a text-box that populates from the "Psychiatric Assessment."

Discharge Summary updates

  • In accordance with CARF 2.B.13.(b)(c)(d)(e), re-titled "Strengths and Preferences" to "Strengths, Needs, Abilities and Preferences."

In the "Strengths, Needs, Abilities and Preferences" section:

  • Programmed the current text-box to populate from the "Comprehensive Diagnostic Assessment."
  • Added a text-box that populates from the "Psychiatric Assessment."

Template updates

  • Added "*NA- Progress Note."
  • Added "*NA- Chart Note."
  • Corrected the code that was causing the provider's name to populate twice.

AutoNote™ updates

  • Added the "Plan" AutoNote™.

In all "Session Details" AutoNotes™:

  • Changed the label of the "Billing Code" text-box to "Service/Billing."

Version 3.0.0 January 13, 2020

Portal / Pre-Screen updates

In the "Insurance Information & Additional Demographics" section:

  • Added detail fields for "Secondary Insurance", including "Policyholder", "Relationship to Insured", and "Co-Pay."

In the "Presenting Condition" section:

  • Removed question "Is this an Emergency, Crisis, or Situation Involving Dangerous Substance Use."

In the "Medical History" section:

  • Added prompt to "Current Medications", "Include Over-the-counter medications, vitamins, herbs, etc." in accordance with CARF 2B-13J.
  • Added specific questions to the "Medical History" section for Tuberculosis, Hepatitis, HIV/AIDS, and STD's.
  • Added a follow up narrative box to "Acute/Chronic Pain."
  • Added prompt to "Medical/Surgical Treatment History", "Include alternative/complementary treatment(s)" in accordance with CARF 2B-13J.
  • Changed the language in the "Nutrition" subsection from "Noncompliance with a Special Diet" to "On a Special Diet."
  • Reversed the display order of "Nutritional Details/Comments" with "What do you do for physical activity / exercise."

In the "Behavioral Health/Substance Use History" section:

  • Added the "Substance Use History" table.

Comprehensive Diagnostic Assessment updates

In the "Medical History" section:

  • Added prompt to "Current Medications", "Include Over-the-counter medications, vitamins, herbs, etc." in accordance with CARF 2B-13J.
  • Added specific questions to the "Medical History" section for Tuberculosis, Hepatitis, HIV/AIDS, and STD's.
  • Added a follow up narrative box to "Acute/Chronic Pain."
  • Added prompt to "Medical/Surgical Treatment History", "Include alternative/complementary treatment(s)" in accordance with CARF 2B-13J.
  • Changed the language in the "Nutrition" subsection from "Noncompliance with a Special Diet" to "On a Special Diet."
  • Reversed the display order of "Nutritional Details/Comments" with "What do you do for physical activity / exercise."

In the "Emotional/Behavioral" section:

  • Changed section the display of the prompt text "(symptom onset, frequency, & duration)" from black to red.

In the "Recovery/Living Environment" section:

  • Added "Basic living Skills/Functional Deficits."
  • Added "Leisure and Recreational Interests."
  • Added "Social and Peer Group Settings."
  • Added "Community Resources Currently Accessed."

In the "Risk Assessment" section:

  • Changed "Protective Factors" to "Protective Factors and Natural Supports."

In the "Strengths and Preferences" section:

  • Added "In the client's words..." to the red prompt text In the "Initial Treatment Plan" section.
  • Added an expandable "Referral" table.

Psychiatric Assessment updates

 Completely redesigned to utilize existing standard sections, and have those sections populate forward where appropriate.

  • Added the standard "Medical History" section, programmed to populate data forward from earlier assessments.
  • Changed the "Psychiatric Review of Systems" from a narrative box to a series of checkboxes, featuring "Client denies" for unselected items.
  • Added the standard "Medical Review of Systems" section, this does not populate.
  • Added the standard "Substance Use History" section, programmed to populate data forward from earlier assessments.
  • Added the standard "Risk Assessment" section, this does not populate.
  • If a safety plan is indicated in this section it will populate to the "Master Treatment Plan."
  • Added the standard "Initial Treatment Plan" section.

History & Physical Exam updates

Completely redesigned to utilize existing standard sections, and have those sections populate forward where appropriate.

  • Added the standard "Medical History" section, programmed to populate data forward from earlier assessments.
  • Added the standard "Initial Treatment Plan" section.

Nursing Assessment update

New assessment for the profile designed to utilize existing standard sections, and have those sections populate forward where appropriate.

  • Includes the standard "Medical History" section, programmed to populate data forward from earlier assessments.
  • Includes the standard "Substance Use History" section, programmed to populate data forward from earlier assessments.
  • Includes the standard "Medical Review of Systems" section, this does not populate.
  • Includes a "Function Screen."
  • Includes the standard "Risk Assessment" section, this does not populate. If a safety plan is indicated in this section it will populate to the "Master Treatment Plan."
  • Includes the standard "Initial Treatment Plan" section.

Master Treatment Plan updates

  • Three lines added to "Initial Goals." Each line will auto populate from the "Initial Treatment" section of the assessments, if used.
  • (Comprehensive Diagnostic Assessment, History & Physical Exam, Psychiatric Assessment, Nursing Assessment).
  • Two lines added to "Safety Plan." Each line will auto populate from the "Risk Assessment" section of the assessments, if used.
  • (Comprehensive Diagnostic Assessment, Psychiatric Assessment, Nursing Assessment) *The "History & Physical Exam" does not include a "Risk Assessment" section.
  • Added a narrative text area in the "Medications" section.
  • Re-titled the "Discharge/Transition Criteria" section to "Discharge/Transition/Aftercare Planning."

In the "Discharge/Transition/Aftercare Planning" section:

  • Added title to first line "Criteria."
  • Added "Medical (Provider; Contact Information; Services to be Provided)."
  • Added "Living Arrangements (Provider; Contact Information; Services to be Provided)."
  • Added "Academic/Vocational (Provider; Contact Information; Services to be Provided)."
  • Added "Therapy (Provider; Contact Information; Services to be Provided)."
  • Added "Other (Provider; Contact Information; Services to be Provided)."
  • Changed "Short-Term Objective" to "Short-Term Objective/Goal."

*The entire "Discharge/Transition/Aftercare Planning" section populates to the "Discharge Summary."

Discharge Summary updates

  • Added "Date of Last Service."

In the "Discharge/Transition/Aftercare Plan" section:

  • Added title to first line "Criteria."
  • Added "Medical (Provider; Contact Information; Services to be Provided)."
  • Added "Living Arrangements (Provider; Contact Information; Services to be Provided)."
  • Added "Academic/Vocational (Provider; Contact Information; Services to be Provided)."
  • Added "Therapy (Provider; Contact Information; Services to be Provided)."
  • Added "Other (Provider; Contact Information; Services to be Provided)."

*The entire "Discharge/Transition/Aftercare Planning" section populates from the "Master Treatment Plan."

Template updates

All progress notes: The "Mental Status" AutoNote™ now has 2 parts (2 visible buttons), "Mental Status" and "Response/Risk"

(see Figure 1-4).

Figure 1-4. "Mental Status" note buttons.

The "Mental Status" button features the following content (see Figure 1-3).

Figure 1-3. "Mental Status" button.

The "Response/Risk" button features the following content (see Figure 1-2).

Figure 1-2. "Response/Risk" button.

Added a standard "Session Details" AutoNote™ to the "*Psy- Progress Note" (see Figure 1-1).

Figure 1-1. "Session Details" AutoNote™.

Version 2.2.1 September 9, 2019

Assessment update

Removed all occurrences of "Relevant" from the "Recovery/Living Environment" section in the "Comprehensive Diagnostic Assessment."

Group note update

Added an area for free typing beneath the drop-down box (see Figure 9-1).

Figure 9-1. New text box.

Version 2.2.0 August 30, 2019

Assessment updates

  • Removed "Communicable Disease" follow-up questions from "Pre-Screen" and "Comprehensive Diagnostic Assessment." 
  • Edited red text under "Abuse, Trauma, Neglect, Exploitation" subsection.

Progress note update

Removed duplicated "Date of Birth" fields from the "DAP" and "SOAP" progress notes.

Version 2.1.0 August 6, 2019

Med/Clinical updates

In the "Medical History" section in the "Pre-Screen" and "Comprehensive Diagnostic Assessment:"

  • Added a follow-up pain scale to "Acute/Chronic Pain" checkbox.
  • Added in-line text box to "Other Medical Conditions" checkbox. 
  • Added a table to "Medical and Surgical Treatment History." 

In the "Substance Use & Withdrawal Potential" section of the "Comprehensive Diagnostic Assessment:"

  • Added "Active Withdrawal Symptoms."

In the "Discharge Summary:"

  • Added a "Strengths and Preferences" section (populates from the "Comprehensive Diagnostic Assessment").
  • Added "Reason for Change to Diagnosis" beneath "Discharge Diagnosis."

Progress note updates

Added the following new progress notes:

  • Peer Support
  • Case Management
  • CBRS

Formatting changes to "UR Review."

Version 1.2.6 June 26, 2019

Progress note updates

All progress notes have been updated to automatically display the client's "Date of Birth (DOB)" and "ID #."

Version 1.2.5 June 24, 2019

Assessment updates

  • The Mental Status Exam in the "Comprehensive Diagnostic Assessment" and the "Psychiatric Assessment" was updated to include "Homicidality" as an option.
  • Minor edits were made to better align the content of the "Mental Status" section between the "Comprehensive Diagnostic Assessment" and "Psychiatric Assessment."

Version 1.2.4 June 6, 2019

Progress note updates

In the SOAP progress note, there is a new "Objectives" AutoNote™ that allows for the documentation of "Problems Addressed", "Objective Addressed", and "Progress" (see Figure 6-2).

Figure 6-2. New "Objectives" AutoNote™.

There is also a new "Mental Status" AutoNote™ that allows the documentation of mental functioning, and signs and symptoms of mental illness (see Figure 6-1).

Figure 6-1. New "Mental Status" AutoNote™.



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