Profile Version Updates


Version 3.2.0 - 03/20/2020

Progress Note Updates

Added a "Telehealth" location option to the Session Details of Progress Notes (see Figure 1-1).

Figure 1-1. Telehealth Location Option


Added selectable options for Readiness to Change in the "Response/Risk" auto-note in Progress Notes (see Figure 1-2).

Figure 1-2. Readiness to Change Options

Assessment Updates

Moved "Eating Habits" from the "Behavioral Health History" section in the CDA to the "Medical History" section by the request of Joint Commission surveyors. This content will display in the "Medical History" sections in the portal application and all assessments (see Figure 1-3).

Figure 1-3. Eating Habits


Psychiatric Evaluation

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 1-4).

Figure 1-4. Clinical Impression and Summary

MTP and DS Updates

Reformatted the "Discharge/Transition/Aftercare" section in the Master Treatment Plan and Discharge Summary for improved Snapshot display (see Figure 1-5).

Figure 1-5. 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 1-6).

Figure 1-6. *Group Therapy Note

Version 3.1.0 - 01/23/2020

CDA 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.”

NA 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 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.

MTP 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 CDA.
  • 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 CDA.
  • 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.

Auto-Note Updates

  • Added the “Plan” auto-note.

In all “Session Details” Auto-notes:

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

Version 3.0.0 - 01/13/2020

Portal / Pre-Screen Updates

In the "Insurance Information & Additional Demographics" section:

  • Added detail fields for Secondary Insurance: 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.

CDA 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 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 check boxes, featuring "Client denies" for unselected items.
  • Added the standard Medical Review of Systems section- does not populate.
  • Added the standard Substance Use History section, programmed to populate data forward from earlier assessments.
  • Added standard Risk Assessment section- 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.

H & P 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- does not populate.
  • Includes a Function Screen.
  • Includes the standard Risk Assessment section- 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

  • 3 lines added to "Initial Goals". Each line will auto populate from the Initial Treatment section of the assessments, if used.
  • (CDA, H & P, Psychiatric, Nursing Assessment).
  • 2 lines added to "Safety Plan",  Each line will auto populate from the Risk Assessment section of the assessments, if used.
  • (CDA, Psychiatric, Nursing Assessment) *The H & P 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 auto-note now has 2 parts (2 visible buttons), Mental Status and Response/Risk

(see Figure 1-7)

Figure 1-7. Mental Status Note buttons.


The Mental Status button features the following content (see Figure 1-6):

Figure 1-6. Mental Status button.


The Response/Risk button features the following content (see Figure 1-5):

Figure 1-5. Response/Risk button.


Added a standard Session Details auto-note to the "*Psy- Progress Note" (see Figure 1-4).

Figure 1-4. Session Details auto-note.

Version 2.2.1 - 09/09/2019

Assessment update

Removed all occurrences of "Relevant" from the Recovery/Living Environment section in the CDA.

Group note update

Added an area for free typing beneath the drop-down box (see Figure 1-3).

Figure 1-3. New text box.

Version 2.2.0 - 08/30/2019

Assessment updates

  • Removed "Communicable Disease" follow-up questions from Pre-Screen and CDA. 
  • 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 - 08/06/2019

Med/Clinical updates

In the "Medical History" section in the Pre-Screen & CDA:

  • 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 CDA:

  • Added "Active Withdrawal Symptoms."

In the Discharge Summary:

  • Added a "Strengths and Preferences" section (populates from the CDA).
  • 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 - 06/26/2019

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 - 06/24/2019

Assessment updates

  • The Mental Status Exam in the "CDA" 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 between the "CDA" and "Psychiatric Assessment".

Version 1.2.4 - 06/06/2019

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 1-1).

Figure 1-1. 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 1-2).

Figure 1-2. New "Mental Status" autonote.
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