Profile version updates

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" check-box 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)" check-box 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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