NOTES:




Documentation


Page Content (click on blue titles):


 User Permissions Required (contact your BestNotes System Administrator for user permissions):

 

Create Tx Plan:

The Create Tx Plan permission allows a user to access Treatment plans, but only use the Add Problem button in the Master Problem List section. These users can see DSM-5 with the DSM-5 Diagnostic Criteria set and Tx Plan Library (Goals, Objectives, and Interventions). NOTE: This does NOT make an official diagnosis and will not be pulled to billing.






Diagnose:

The Diagnose permission must also have the Create Tx Plan permission (see above). The Diagnose permission is required to assign a diagnosis using ICD-10 codes. An "As evidenced by" textbox will appear. (NOTE: A detailed list of diagnostic criteria will only appear when the DSM-5 code set is selected.)





Add DSM-5 Dx:

The Add DSM-5 Dx permission must also have the Diagnose permission (see above). This permission will include the DSM-5 set of Diagnostic Criteria and the Tx Plan Library (Goals, Objectives, and Interventions library. See documentation below or Click HERE.








Create Tx Plan 
(Access to Tx Plans)
Create Tx Plan
+Diagnose
Create Tx Plan
+Diagnose
+Add DSM-5 Dx
Billable
No
Yes
Yes
Diagnose
NA
ICD-10 only
ICD-10 & DSM-5


DSM-5 Diagnostic Criteria
Add Problem button
+DSM-5 only
Add Problem button
+DSM-5 only
Add Problem+DSM-5 only
and
Diagnose+DSM-5 only
Add Problem(s) button
ICD-10 & DSM-5
ICD-10 & DSM-5
ICD-10 & DSM-5
When you will only see the

ICD-10 Code System
As evidenced bytextbox
Add Problem button
+ICD-10 only

Add Problem+ICD-10 only 
and 
Diagnose+ICD-10 only
Add Problem+ICD-10 only
and 
Diagnose+ICD-10 only


BestNotes DSM-5
Tx Plan Library
(only made for DSM-5 codes)

 
Add Problem button only
if you use the DSM-5 code system
OR
Search for DSM-5 codes in
the ICD-10 code system
 
Add Problem button
if you use the DSM-5 code system
OR
Search for DSM-5 codes in
the ICD-10 code system
and
 
Diagnose if you use the
Search for DSM-5 codes in
 
the ICD-10 code system


Add Problem and Diagnose
If you use the DSM-5 code system
OR
Search for DSM-5 codes in
the ICD-10 code system

Display customized
Tx Plan Library
+

BestNotes

Tx Plan Library (see above)


(To customize, 
Click HERE)
Add Problem button only
with both
ICD-10 and DSM-5
Add Problem button
with both
ICD-10 and DSM-5
and
Diagnose with ICD-10 only
Add Problem and Diagnose
with both
ICD-10 and DSM-5











An important note: The American Psychological Association (APA) required BestNotes to sign an updated agreement to transition from distributing the DSM-IV-TR codes and diagnostic criteria to DSM-5. In the new agreement, the APA significantly increased the fees it charges BestNotes. As a result, a $4.00 per month DSM-5 subscription fee will be charged for each BestNotes user with the Add DSM-5 Dx permission setting to assign DSM-5 codes to a patient. 




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ICD-10 or DSM-5 Diagnosing






When entering a diagnosis for ICD-10 or DSM-5:

  • Select either: ICD-10 or DSM-5


  • Start with the Category dropdown
    • NOTE: ICD-10 categories are the Medical Chapters. The following option is more efficient for ICD-10.
OR
  • Quick Search box (Search by Code and /or Name





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NOTE: If you select the Code Search dropdown without selecting a category you will receive this warning:


Selecting the dropdown alone would try to display all 68,000+ codes at once. It is best practice to search or select a category first.




When entering the official diagnosis in the Master Treatment Plan (used for Insurance billing and {XDIAGNOSIS} special field to display/populate Dx in other parts of BestNotes):

  • Select the Diagnosis as shown above
OR
  • Select from the previous Diagnoses' dropdown menu (next to Add Diagnosis) to manually Transfer an Assessment Diagnosis or Initial Treatment plan selection. (NOTE: This will need to be turned on by your BestNotes Implementer with a ticket request).







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DSM-5 Goals, Objectives and Interventions


In the Master Tx Plan, adding a diagnosis (pulling from Initial or adding official diagnosis) OR with the Add Problem button, you will be prompted to add the following:


Long Term Goals:


A list of predefined goals and blank spaces to enter your own goals. Next to each goal is a check box to click if you want the goal inserted into the final Master Treatment (Tx) Plan. When finished selecting goals, click the Next button, this will take you to the Objectives selection screen.


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Objectives:


A list of predefined objectives and space to create your own objectives. Next to each objective is a check box to click if the objective needs to be inserted into the final Master Treatment (Tx) Plan.


NOTE: Once checked or added, below each objective are checkboxes to link the objective to a goal(s). Goals can be re-ordered under the Master Treatment Plan list.


When finished selecting objectives, click the Save and Continue button. This will take you back to the Interventions selection screen.

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Interventions:


A list of predefined interventions and space to create your own objectives. Next to each intervention is a check box to click if the intervention needs to be inserted into the final Master Treatment (Tx) Plan. When finished selecting interventions, click the Save and Continue button. This will return the user to the Master Treatment (Tx) Plan worksheet.



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Each intervention allows the flexibility to enter in the frequency that they will occur.


Each of the three areas Long Term Goals, Objectives and Interventions is edited from the Tx Plan Library section in the settings area of BestNotes. 


For more documentation on managing the DSM-5 library, Click HERE.




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Custom Problems


  1. Create Custom problems.
  2. In the Initial / Master Tx Plan, select Custom Problems from the dropdown Menu.




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Reports



TPL: Displays a quick glance of what diagnoses the company is giving, the percentage of clients given a specific diagnosis and the percentage resolved. This can be seen for all current and past clients and can be narrowed to a specific axis. 


Diagnoses by Client: based on a date range of the client's start (DOA) and end date (DOD).
  • Diagnosis - displays CID (unless AltID field is used), Name, Date of Birth (DOB) Sex, Admit date (Start date - DOA), Discharge Date (End date - DOD), Therapist (Provider 1), Diagnosis List.
  • Problem List - displays ID (for when AltID field is used), Name, Date of Birth (DOB) Gender, Therapist (Provider 1), Admit date (Start date - DOA), Discharge Date (End date - DOD), Problem list (goals, objectives Added / Resolved)



For more documentation on reports, click HERE.



 


At this time, all users who need to migrate to DSM-5 need all three permissions. See documentation below.






Before migrating to DSM-5, there are two scenarios to consider:

  • Your company finishes current patients with DSM-IV

OR

  • Migrate current clients with past and future patients to DSM-5.


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NOTE: Your company will be charged an additional $4 per user, per month when the DSM-5 permission box is checked. This is in accordance with the APA Subscription Fee for the DSM-5 Codes and Diagnostic criteria.

BestNotes does not profit from this additional fee. More information available at the bottom of this page.


After you receive the DSM-5 permission, make sure each patient, who needs to transition, has current and/or updated snapshots for all DSM-IV diagnosis documents.

 

When "Save Snapshot and Migrate to DSM-5 Tx Plan" is clicked:

  1. A window opens with more information and to acknowledge this patient is ready
  2. BestNotes takes a final snapshot of the document you’re viewing 
  3. All yellow DSM-IV diagnosis treatment plans with 5 Axises will be removed for that patient
  4. A new BLANK Blue DSM-5 version without 5 Axises displays
  5. ICD-9 and ICD-10 will be together for a new diagnosis
  6. All other information will be left intact, including: 
  • Problems 
  • Goals 
  • Objectives 



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NOTE: BestNotes cannot return the DSM-IV diagnosis after the transition.