Behavioral Health Profile Updates

Profile Version Updates

Version 2.6.3 - 06/26/2019

All Progress Notes

All progress notes have been updated to automatically display the client's Date of Birth (DOB) and ID #.

Version 2.6.2 - 06/06/2019

Med/Clinical Updates

The Substance use Assessment was updated to now include a "Mental Status Exam" (see Figure 1-27).

Figure 1-27. Part of the new Mental Status Exam.

Progress Note Update

The order of the content within the "Data" autonote was adjusted.

Version 2.6.0 - 05/30/2019

Med/Clinical Updates

The CDA documents Mental Status Exam now include the option "Homicidality" in the "Thought Content and Perception" section (see Figure 1-20).

Figure 1-20. "Homicidality" added to the Mental Status Exam

Within the CDA the "Initial Goals and Milestones" field was updated to "Initial Goals" to improve clarity (See Figure 1-21). This will still populate the Master Treatment Plan in the same manner as before.

Figure 1-20. Initial Goals reworded.

In the Master Treatment Plan and the Discharge Summary, the section titled "Status of Continuing Care / Discharge Criteria" has been updated to "Discharge / Transition Planning". The "Medical", "Living Arrangements" Academic/Vocational", "Therapy (Individual, Group, Family, Etc.", "Other Supports", "Justification for Continued Treatment" within that section were simplified to "Recommended Services" and "Referrals Needed" (See Figure 1-22).

Figure 1-22. Updated sections and fields in the Master Treatment Plan and Discharge Summary.

The Master Treatment plan was rearranged slightly to improve the workflow. The "Dicharge Criteria" and "Discharge / Transition Planning" and "Crises Plan" sections were moved to display together after the "Problem Detail" area and their order was updated (see Figure 1-23).

Figure 1-23. Updated sections in the Master Treatment Plan.

Progress Note Updates

The Progress notes were updated to be more efficient and effective, the following Autonotes were updated.

The "Data" autonote has the following updates

  • Now displays "Goal", "Objectives" and "Intervention and Education" for All Progress Notes (see Figure 1-24).
  • "Goals and objectives allow for you to be able to select, or add free text, keeping this optional without implying an omission of content in the finished product (see Figure 1-24).
  • "Prevention / Collateral Services" now displays (*CL Progress Note only) (see Figure 1-24).

Figure 1-24. Data Autonote Updates

Within the clinical "Assessment" autonote, the "Mental Status" and "Response/Risk" sections were updated (see Figure 1-25 and 1-26).

Figure 1-25. Mental Status Autonote updates.

Figure 1-26. Response/Risk Autonote updates

Version 2.5.0 - 03/12/2019

Since the Idaho Profile contains Clinical standards that also apply to outpatient behavioral health providers in other states, we have renamed this profile to "Outpatient Behavioral Health Profile".

Several items were added to the Online/Portal Application. Added Demographics to page 1 (see Figure 1-16). Added Additional Related Contact to page 1 (see Figure 1-17). Streamlined the content and added "Secondary Insurance" which is also on the Pre-Screen, also located on page 1 (see Figure 1-18).

Added "Medication Management" as an intervention option in the Behavioral Health Treatment History Table (see Figure 1-19).

Custom Fields are now available within the profiles!

Figure 1-16. Demographics.

Figure 1-17. Additional Related Contact.

Figure 1-18. Secondary Insurance.

Figure 1-19 Medication Management as an option.

Version 2.4.9 - 01/23/2019

Added "Thought Process" to the CDA and PE (see Figure 1-12). Removed red text on the Pre-Screen and SUA assessments (see Figure 1-13). Added a text box to the autonote "*CL - Progress Note" (see Figure 1-14). Added "Units" to the autonote "*CM - Progress Note" (see Figure 1-15).

Figure 1-12. Added "Thought Process".

Figure 1-13. Removed Red Text.

Figure 1-14. Added Text box.

Figure 1-15. Added "Units".

Version 2.4.7 - 01/07/2019

The diagnosis was added to the "*CBRS-Progress Note". There is now a prompt to explain narrative section in the "*Group Note" (see Figure 1-10). The Psychiatric Evaluation has updated section titles, and reordered sections (see Figure 1-11).

Figure 1-10. New Prompt in *Group Note.

Figure 1-11. Updated sections and titles in Psychiatric Evaluation.

Version 2.4.6 - 12/18/2018

Psychiatric Evaluation in the Med/Clinical was updated (see Figure 1-8). Substance Use Assessment had a field updated (see Figure 1-9).

Figure 1-8. Psychiatric Evaluation was updated.

Figure 1-9. SUA field updated.

Version 2.4.4 - 12/10/2018

There is a New Collaboration Note (see Figure 1-2). Updates have been made to the Peer Support and Recovery Coaching Assessment templates (see Figures 1-3 to 1-6). Another addition was made to the "Recovery Wellness Plan" (see Figure 1-7).

Figure 1-2. New Collaboration Note.

Figure 1-3. Updates to PS RC Assessment Templates.

Figure 1-4. Updates to PS RC Assessment Templates.

Figure 1-5. Updates to PS RC Assessment Templates.

Figure 1-6. Updates to PS RC Assessment Templates.

Figure 1-7. Addition to Recovery Wellness Plan Template.

Version 2.4.2 - 11/13/2018

Within the CDA, adjustments were made to wording and order in the "Mental Status Exam", and "Basic Living Skills" added to the "Social History" section. Within the Psych Eval, adjustments were made to wording and order in the Mental Status Exam". Allergies and a breif Mental Status Exam have been added to the Medical Progress Note. Details regarding changes to the most recent Med/Clinical documents can be seen by clicking on the question mark at the top of the document (see Figure 1-1).

Figure 1-1. View Med/Clinical most recent changes.

Version 2.3.0 - 10/30/2018

We would like to extend a special "Thank You" for your valuable input and feedback! The changes reflected in these updates are a direct result of ongoing collaboration with providers! Please keep the feedback coming!

There have been udpates made to the Med/Clincal Area.

The CDA has a simplified "Risk Assessment", and "Clinical Formulation and Medical Necessity" sections. The wording has been edited in the "Behavioral Health History" section. Also, adjustments have been made so that any unchecked checkboxes will not appear on snapshot.

The SUA has had significant edits to the "Clinical Formulation and Medical Necessity", and "ASAM Dimension" sections. These edits are intended to bring hte document into closer alignment with the CDA.

Version 2.2.2 - 10/11/2018

Some wording and formatting edits have been made to the Gorup Note. In the Med/Clinical, wording edits have been made to the "Behavioral Health History" section, added new Medical Necessity questions to the Clinical Formation and implemented a setion ordering fix.

Version 2.2.0 - 10/04/2018

There have been several updates to different documents for this version. The templates have been reorganized to be preceded by the service/doctype. For example, clinical documents will be preceded with "CL" and peer support documents are preceded by "PS" etc. The three PSRC templates were duplicated, and one set of each was renamed as either PS or RC, and added the initial discharge plan to both assessments. Another new template was created, *CM-Assessment.

There is also an update to the Group Note with streamlined format. We removed days of the week and extra Group box, adding billing, risk and next appointment.

Version 2.1.0 - 09/28/2018

Edits have been made to the Clinical, Case Management, and CBRS Progress Notes. There have been 4 new templates created

  • Peer Support/Recovery Coaching Assessment (*PSRC - Assessment)
  • Peer Support/Recovery Coaching Wellness Plan (*PSRC - Wellness Plan)
  • Peer Support/Recovery Coaching Progress Note (*PSRC - Progress Note)
  • Family Support Services Progress Note (*FS - Progress Note)

These updates are actively addressing all of the "Optum Idaho Network Provider Audit Tool Documents", and we will continue to add to and adjust the offerings in this profile documentation set as we acquire feedback and as regulations change. These documents can be found here.

Version 2.0.1 - 09/14/2018

There is new content in the Clinical, Case Management, and CBRS Progress Notes. The changes in each of these templates contain needed changes to their respecitve Optum audit tools nad new (July 2018) Level of Care Guidelines.

Version 2.0.0 - 09/06/2018

There have been updates to two different templates in the profile. The "*C-Progress Note, Clinical" has had some minor formatting edits. The "C-Progress Note, Case Management" has had some formatting edits and some significant content updates.

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