- Ready-to-use clinical documentation
- Audit & accreditation compliant
- Pre-programmed for intelligent movement of data
- Automatic updates
The Clinical Profile was created to eliminate anxiety about new regulations and audits. This clinical documentation and workflow adheres to common state regulations, UnitedHealth's (Optum) level of care guidelines and audit tools, as well as standards recommended by The Joint Commission and CARF. Our in-house clinical team has worked hard to maintain an efficient workflow by eliminating redundancies and double-data entry. The best part: BestNotes will automatically update and maintain this documentation for you!
Clinical Profile content
The documentation included in the Clinical Profile are listed below.
Pre-Screen/Intake
Online Patient Application and Pre-Screen
Level of Care Criteria (Dimensional Crosswalk)
Assessments
Comprehensive Diagnostic Assessment (Multi-Dimensional Format)
History and Physical Exam
Psychiatric Evaluation
Medical Assessment
Treatment planning
Master Treatment Plan
Utilization Review
Discharge Summary
Delivery of care
Progress Notes: Clinical, Psychiatric, Medical, CBRS, Peer Support, and Case Management
Group Therapy Note
Drug UA Results Note & Report
Operational support
Collaboration of Care Note
Missed Service Note
Treatment Team Note (Staffing)