Profile Version Updates

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 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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