Behavioral Health Profile updates

Profile version updates

Version 6.5.0 November 3, 2023

Assessment updates

In all "Additional Demographics" sections:

  • Removed "Preferred Language" and "Marital Status" as they are now included in the "Demographics" section.
  • Added "Do you have any special communication needs (e.g. sign language)."

In all "Presenting Condition/HPI" sections:

  • Updated the red provider facing prompt text to: "Reflect the client's own words and verbatim explanation as to why they are here for help, (covering their presenting needs/issues/problems.) When applicable and permitted, relevant information from family (significant others) and other collateral sources. Address precipitating factors; current circumstances of living; and your sources of information."

In all "Medical History" sections:

  • Change "Primary Care Physician" to: "Primary Health Care Provider" and removed the field for "Last Name" to allow for the name of a facility to be entered.
  • Under "Medical Conditions", added additional follow-up checkboxes which display when "Acute/Chronic Pain" is selected.
    • Pain Assessment Indicated
      • Supplemental Tool/Assessment Used (populates additional Prompt Text to the "Supplemental Assessment Tools / Records" section).
      • Referral Needed (populates additional Prompt Text to the "Initial Treatment Plan" section Referrals Needed/Provided subsection).

  • Under "Medical / Surgical Treatment History":
    • Updated the red provider facing prompt text to: "Include any recent emergency care and alternative/complementary treatment(s)."
    • Changed "Medical Condition" to "Procedure / Medical Condition."
  • Revamped the Nutrition Section:
    • Added "(including special dietary needs and restrictions associated with medication use)" to "On a Special Diet."
    • Added additional follow-up checkboxes for "Eating Habits or Behaviors that may be Indicators of an Eating Disorder":
      • Bingeing
      • Inducing Vomiting
      • Excessive Restriction/Avoidance of Food
      • Frequent Use of Laxatives
      • Ingestion of Non-Food
    • Added "Nutrition Assessment Indicated" with two follow-up checkboxes:
      • "Supplemental Tool/Assessment Used" (populates additional Prompt Text to the "Supplemental Assessment Tools / Records" section).
      • "Referral Needed" (populates additional Prompt Text to the "Initial Treatment Plan" Referrals Needed/Provided subsection). 
    • Added "None Reported" to the "Nutrition" subsection in the "**CDA/BPS."
  • Moved "Family Medical History" to the end of the "Medical History" section.

In all "Substance Use History" sections:

  • Re-ordered content for a more natural flow:
    • "IV Drug Use", "Have you ever shared needles", and "Any instances of Overdose" moved directly below the "Substance Use" table. 
    • "Active Withdrawal Symptoms Reported or Observed" are now hidden by default unless checked.
    • If "Supplemental Assessment Used (i.e. COWS, CIWA)" is checked, additional prompt text appears in the "Supplemental Assessment Tools / Records" section: "COWS/ CIWA Used (Record details below)."
    • "Impact of Substance Use/Addiction on Daily Living" moved directly below "Active Withdrawal Symptoms."
    • "Previous Diagnoses" moved to the bottom of the section, directly above "Family History of Mental Health, Substance Use, Gambling, or Other Addictive Behaviors."

In the "Social History" section of the "*Pre-Screen/IA":

  • Updated the "Legal Needs or Considerations" label to: "Legal Needs or Considerations: (Arrests, Court appearances, Fines, Separation/divorce, Loss of custody, Incarceration)."

In the "Behavioral Health History" section of the "*Pre-Screen/IA":

  • Updated the "Trauma, Abuse, Neglect, Exploitation" label to: "Trauma, Abuse, Neglect, Exploitation: (Please describe any incidences where you have been a victim, perpetrator or witness of current or past trauma, physical abuse, sexual assault, neglect, domestic or neighborhood violence, sexual or any other type of exploitation, or other adverse life experiences)."

In the "Behavioral Health History" section of the "CDA/BPS":

  • Updated the red provider facing prompt text of "Trauma, Abuse, Neglect, Exploitation" to: "Explain client's experience (as victim, perpetrator, or witness) of trauma, abuse, neglect, or exploitation, physical abuse, sexual assault, neglect, domestic or neighborhood violence, sexual or any other type of exploitation, or other adverse life experiences). Abuse, neglect, and exploitation must be reported to authorities per law and regulation, and documented. Consider client's exposure, intrusion, avoidance, negative alterations in cognition/mood, arousal, reactivity, dissociative symptoms?"

In the "Social History" section of the "*CDA/BPS":

  •  Updated red provider facing prompt text:
    • Under "Family History", added: "including divorce, bereavement, incarceration of significant other."
    • Under "Basic Living Skills / Functional Deficits", added: "Food Insecurity?"
    • Under "Vocational/Employment Needs or Considerations", added: "Include brief employment history."
    • Under "Financial Needs or Considerations", added: "Include any difficulty accessing and/or paying for health care and/or medications."
    • Under "Educational Needs or Considerations", added: "Include brief educational background/history and literacy levels."
    • Under "Legal Needs or Considerations", added: "Include Arrests, Court appearances, Fines, Separation/divorce, Loss of custody, Incarceration."
    • Under "Cultural Considerations", added: "Include preferences and any variables that may impact treatment."
    • Under "Religion / Spiritual Orientation", added: "Include any beliefs or variables that may impact treatment."

In all "Strengths, Needs, Abilities and Preferences" sections: 

  • Updated red provider facing prompt text to: "In the client's words: strengths, needs, abilities, and treatment preferences, e.g., time availability and barriers to treatment, gender of counselor, leisure time/recreational activities, spiritual activities, individual or group therapy, medication, time availability."

In all "Supplemental Assessment Tools / Records" sections:

  • Updated red provider facing prompt text to: "Please include any ancillary resource(s) having bearing on your Provider Interpretive Summary and Clinical Formulary. e.g. Scales/Measurements (CSSRS-Triage, LEC-5, PHQ-9), Assessments, Level of Care Criteria's, Consultation Reports, etc."
  • Added reminder prompt text which will appear if indicated for:
    • COWS/ CIWA Used (Record details below)
    • Pain Assessment Used (Record details below) 
    • Nutrition Assessment Used (Record details below) 
  • Added new "Completed By" column to the "Supplemental Assessment Tools / Records" table.
  • The "Supplemental Assessment Tools / Records" table is now mirrored with population between assessments.

In the "Clinical Formulation & Medical Necessity" section of the "*CDA/BPS":

  • Updated the "Recommended Level of Care" drop-down for "Formulation by LOCUS" to include "CALOCUS Levels of Care."
  • Updated the "Clinical Formulary of Client's Needs and Severity of Risk" label so that it now reads: "Provider Interpretive Summary and Clinical Formulary of Client's Needs and Severity of Risk."
  • Updated the red provider facing prompt text to: "Based on the assessment data, detail the individual's relevant clinical history and the biological, psychological, and social factors including co-occurring disabilities, comorbidities, and/or disorders indicating clinically significant distress or impairment in social, occupational, or other important areas of functioning."

In all "Initial Treatment Plan" sections:

  • Added new red provider facing prompt text under "Initial Goal(s)": "Record Client Stated Goal(s), e.g., 'What is the most important thing you'd like to accomplish during treatment?'."
  • Updated the "Case Management" recommended service to "Case Management/PRP."
  • Added prompt text under "Referral(s) Needed/Provided" to include "Pain Assessment" and "Nutrition Assessment" if indicated in the "Medical History" section.
  • Added new "Referral Type" column to the "Referral(s) Needed/Provided" table with options for "In-House" and "External."
  • The "Referral(s) Needed/Provided" table is now mirrored and will populate between assessments.

Treatment Plan Updates

In the "Discharge/Transition/Aftercare Plan(ning)" sections:

  • Added "Anticipated Referrals" label to the "*MTP."
  • Added "Referrals" label to the "*DS/Transition."

Version 6.0.0 June 20, 2023

Portal Updates

The Portal Application now allows for the inclusion of a limited set of pre-defined variables enabled upon request. The text label prompt for Variable 2 is the only element that can be uniquely determined by your company..

The available variables are as follows:

  • Portal Variables 1 and 2:

  • Portal Variable 3:

  • Portal Variable 4:

Assessment updates

In all "Additional Demographics" sections:

  • Removed the word "Attained" from "Highest Level of Education Attained" to allow for a larger text response.

In the "Medical History" section of the "*Pre-Screen/IA":

  • Added codes to pull Medications and Allergies from the "Meds" and "Allergies" tabs respectively to eliminate redundancy when the "*Pre-Screen/IA" is not completed via the Client Portal.

In all "Substance Use & Withdrawal Potential" sections:

  • All "Active Withdrawal Symptoms" text areas now align right for a cleaner look.

In the "Behavioral Health History" section of the "*CDA/BPS":

  • Resolved "(Symptom onset, frequency, & duration)" red provider prompt text displaying on snapshot and moved to a new line.
  • Removed indentation on all text areas to align with standard formatting.

In "Readiness to Change/Stage of Change" section of the "*CDA/BPS":

To clarify that this section is co-occurring content:

  • Updated section label from "Readiness to Change" to "Readiness to Change / Stage of Change." 
  • Removed the phrase "in recovery" from the red provider prompt text.

In the "Clinical Formulation & Medical Necessity" section of the "*CDA/BPS":

  • Moved "Provider Summary and Clinical Formulary of Client's Needs and Severity of Risk" label and accompanying red provider prompt text below the "Select Formulation" options to reduce confusion (see Figure 13-1).
  • For "Formulation by LOCUS": Changed "Dimension" to "Parameter" in accordance with AACP (see Figure 13-1).
  • Split "Parameter IV" into "Parameter IV.A - Recovery Environment (Level of Stress)" and "Parameter IV.B - Recovery Environment (Level of Support)" (see Figure 13-1).

Figure 13-1. "LOCUS Formulation."

In all "Medical Review of Systems" sections:

  • Aligned checkboxes in the "Genitourinary / Urology" subsection for a cleaner look.

In the "Social History" sections of the "*Psych Eval" and "*H&P Exam":

  • Corrected a grammatical error in the red provider prompt text.

In all "Initial Treatment Plan" sections:

  • Shortened the text area for "Drug Testing Rationale" to avoid a wrapping issue.

In the "Family" section of the "*CM ASMT & Plan":

  • Corrected a grammatical error.

In the "Discharge/Transition Summary":

  • Updated titling from "Discharge" to "Discharge/Transition."
  • Moved "Reason for Discharge/Transition" to come after "Levels of Care."
  • Reordered the section "Inactive Problem List" to come directly after "Active Problem List."

Version 5.9.0 January 17, 2023

Assessment updates

In all "Additional Demographics" sections:

  • Updated "Preferred Language" drop-down select box to match the Edit Client FHIR list.

In all "Initial Treatment Plan" sections:

  • Added "Wellness Plan" to "Recommended Services."
  • Added "Safety Plan" to "Recommended Services."
  • Changed "Recovery Services" to: "Peer Support / Recovery Coaching Services."
  • Removed "Community-Based Support."
  • Set all checkboxes to display on snapshot.

Template updates

In all Progress Notes:

  • Updated the “Session Details” AutoNote™ to include remote/telehealth options of "Remote/Telehealth-In home" and "Remote/Telehealth-Out of Home."

In the "*Medical- Progress Note" and the "*PSY- Progress Note":

  • Updated the "NA_PN_MED_ROS (Medical ROS)" AutoNote™ to allow users to both report and deny items without needing to "Append Multiple" (see Figure 12-1).

Figure 12-1. "NA_PN_MED_ROS (Medical ROS)."

Version 5.8.0 July 25, 2022

Assessment updates

*The "*Nursing Assessment" has been retitled "Medical Assessment" to broaden the scope. The same change was made for the associated "*NA- Progress Note" and "*NA- Chart Note."


In all "Medical History" sections:

  • Reprogrammed all medical condition checkboxes to stay visible on snapshot even if not checked.
  • Converted "Current and/or Past Medical Conditions" details from a static label and textbox to a checkbox and dependent textbox. 
  • Converted "Nutritional Details / Comments" from a static label and textbox to a checkbox and dependent textbox.

In all "Substance Use History" sections:

  • Combined "Age of 1st Use" & "Age Became a Problem" into one column and reinstated a column for "Symptoms, Withdrawal, Cravings, Increased Tolerance" (see Figure 11-5).
  • Reinstated Method/Means of Acquisition Table (see Figure 11-5).
  • Changed "Family Mental Health / Substance Use History" to "Family History of Mental Health, Substance Use, Gambling, or Other Addictive Behaviors."
  • Changed "Longest Period of Sobriety and Anything That Helped You Accomplish That Time" to "...Recovery/Sobriety."

Figure 11-5. "New column and table in Substance Use & Withdrawal Potential."

In all "Mental Status Exam" sections:

  • Reprogrammed all checkboxes to stay visible on snapshot even if not checked.

In all "Risk Assessment" sections:

  • Made "Imminent Danger" a separate selectable option (see Figure 11-4).

Figure 11-4. "Imminent Danger in Risk Assessment."

In the "Additional Demographics" section of the "*Pre-Screen" and "*CDA/BPS":

  • Updated options in the "Preferred Language" drop-down.

In the "Clinical Formulation & Medical Necessity" section of the "*CDA/BPS":

  • Added new Formulation by LOCUS option (see Figure 11-3).
  • Changed the title of "Dimension 1" in the "Formulation by Dimension" to "Dimension 1: Acute Intoxication and/or Withdrawal Potential."

Figure 11-3. "Formulation by LOCUS."

In the "Behavioral Health History" section of the "*CDA/BPS":

  • Replaced "Shopping?" with "Other Process Addictions?" in the red text for "Other Addictive or Compulsive Behaviors."

In the "Social History" section of the "*CDA/BPS":

  • Added "Meaning, Purpose, and Values."

In the "Physical Exam" section of the "*H & P Exam":

  • Removed "Neck" as it was redundant to "HEENT" and removed "Rectal" due to lack of relevance.

In the "Master Treatment Plan":

  • Removed the "Strengths, Needs, Abilities, and Preferences" population from the Case Management Assessment & Plan due to redundant display.
  • Reworked the "Acknowledgements" labeling.

In the "Case Management Assessment & Plan":

  • Typo corrections.

Template updates

In all "Progress Notes":

  • Reprogrammed the "Data" AutoNote™ to only pull in active objectives from the Treatment Plan.
  • Removed "Missed Appointment" from the "Session Details" AutoNote™.

In the "*CL- Progress Note":

  • Split the "Data" AutoNote™ into two buttons for the visual ease of providers.

In the "*PSY- Progress Note":

  • Added "Session Type" options to the "Session Details" AutoNote™ to include "with Medication Review" and "without Medication Review."

In the "Assessment" AutoNote™ of the "*CM- Progress Note" template:

  • Changed "Progress toward goals & ongoing assessment of capacity to independently access services" from a prompt label to an independent text area to ensure completion.


Version 5.7.0 January, 2022

Assessment updates

In the "Insurance Information" section of the "Portal / Pre-Screen":

  • Re-ordered text fields for a more logical flow and added "Policyholder DOB" (see Figure 10-7).

Figure 10-7. "Insurance Information."

In all "Medical History" sections:

  • Added COVID-19 "Booster" text box and "Not Vaccinated" checkbox (see Figure 10-1).

Figure 10-1. COVID-19 "Booster" text box and "Not Vaccinated" checkbox.

In the "Substance Use History" sections:

  • Changed "How are these substances acquired" to "Are you encountering any degree of risk when you are acquiring substances" with "Please describe, if comfortable" text area (see Figure 10-2).

  • Added a previous diagnoses question and a previous diagnosis table (see Figure 10-3).

Figure 10-2. Updated "How are these substances acquired."

Figure 10-3. Previous Mental Health or Substance Use Diagnoses.

In the "Social History" section of the "CDA/BPS":

  • Added "(SDOH) Social Determinants of Health" label and definition(see Figure 10-4).
  • Added "Other (SDOH) Social Determinant of Health" option.

Figure 10-4. Social Determinants of Health prompt text.

In the "Clinical Formulation & Medical Necessity" section of the "CDA/BPS":

  • Added clarification labeling (see Figure 10-5).

Figure 10-5. "Clinical Formulation & Medical Necessity" clarification labeling.

In all "Initial Treatment Plan" sections:

  • Added "Need for Assistive Technology" checkbox and text box (see Figure 10-6).

Figure 10-6. "Need for Assistive Technology" checkbox.

In the "Case Management Assessment & Plan":

  • Programmed "Strengths, Needs, Abilities, & Preferences" to auto populate from the "CDA", for those on the "Acuity Set", this populates from the "**NA."
  • Changed the drop-down language from "Independently" to "Completely Independent."

Version 5.6.0 August 26, 2021

Assessment updates

*New Med/Clinical Case Management Assessment & Discharge Summary with supporting Treatment Plan Library Content is now available upon request. 


These documents were designed in accordance with UnitedHealth (Optum) standards and guidelines for Case Management, and feature:

  • Nine standard Case Management domains with selectable options for the client's intensity of need and the prioritization of those needs (see Figure 9-1).
  • A "Treatment Planning and Review" section that works in tandem with the new Case Management specific Treatment Plan Library content (see Figure 9-2).
  • A "Summary of Referral/Collaboration" section designed specifically for Case Management referral activities (see Figure 9-3).
  • Includes an associated standalone "Case Management Discharge Summary."

Figure 9-1. Example of completed Case Management Domain.

Figure 9-2. "Treatment Planning and Review" section of new "Case Management Needs Assessment."

Figure 9-3. "Summary of Referral/Collaboration" section of the new "Case Management Needs Assessment."

In the "Medical History" sections:

  • Added a checkbox to indicate COVID-19 Vaccination and added Vision and Hearing Impairment to Medical Conditions (see Figure 9-4).

Figure 9-4. COVID-19 and new Medical Conditions.

In the "Substance Use History" sections:

  • The column for "Withdrawal, Cravings, Increased Tolerance" in the Substance Use History Table has been removed as it is addressed when selecting the appropriate diagnostic criteria for substance use diagnoses.
  • Added "Pattern Of Use" options to the Substance Use History Table with a follow-up text area for how substances are being acquired, replacing the need for an additional table (see Figure 9-5).

 

Figure 9-5. Substance Use History Table.

In the "Formulation by Dimension" section of the "Clinical Formulation and Medical Necessity" in the "CDA/BPS", added the following levels of care:

  • Level 1- Ambulatory Withdrawal Management w/o Extended On-Site Monitoring.
  • Level 2- Ambulatory Withdrawal Management w/ Extended On-Site Monitoring.
  • Level 3- Residential/Inpatient Withdrawal Management.
  • Level 3.2- Clinically Managed Residential Withdrawal Management.

In the "Discharge Summary":

  • The population coding was updated for "Presenting Condition", "Strengths, Needs, Abilities, and Preferences", and "Treatment Planning Participation by Family or Significant Others." It is now coded to mirror data from the Master Treatment Plan in order to correct inconsistent population.

Template updates

Diagnosis Population in all Progress Notes:

  • Previously, a client's diagnosis was hardcoded to auto-populate from the Master Treatment Plan directly into the body of the note.
  • Now, client diagnoses (Initial and Master) are available for provider selection via AutoNote™ buttons shown below (PN_CL_DIAGNOSIS_ATP) (see Figure 9-6).

Figure 9-6. Progress Note Diagnosis Selections.

Group Note Updates

In the "*Drug Testing Results" Group Note:

  • Added the client's date of birth.

In the "*Group Note":

  • Added Initial Diagnosis (see Figure 9-7).

Figure 9-7. Group Note Diagnoses.

Portal Updates

  • Changed the prompt for "Sex" to "Sex at Birth."
  • Added a prompt label to "First Related Contact" that reads "Please be sure to indicate at least one emergency contact."

Version 5.5.0 March 24, 2021

Assessment updates

In the "Mental Status Evaluation" section of the "CDA/BPS", "Nursing Assessment", "Psychiatric Assessment", and "SUA":

  • Changed the "Thought Content & Perception" subsection to clearly contain three subsections for "Thought Content", "Perception", and "Thought Process" (see Figure 8-3).

Figure 8-3. Mental Status Evaluation.


In the "Risk Assessment" section of the "CDA/BPS", "Nursing Assessment", "Psychiatric Evaluation" and "SUA":

  • Per recommendation from The Joint Commission, added an area for overall risk level selection and narration.

In the "Psychiatric Review of Systems" section of the "Psychiatric Evaluation":

  • Added "Issues with" in front of the symptomology labels ("Sleep" through "Anxiety/Panic Attacks").

In the "Discharge Summary":

  • Replaced the "Summary of Progress" section with BestNotes' standard "Problem Detail" section (as seen in the "Master Treatment Plan"), allowing population and full visibility of itemized "Reviewed/Updated" data that is recorded in the "Master Treatment Plan" at the time of "Treatment Plan Review." This allows for seamless inclusion of discipline specific treatment plans.

In the "*Pre-Screen" Assessment:

  • Changed the title from "*Pre-Screen Assessment" to "*Pre-Screen / Intake Assessment."

Template updates

In the "*PSY- Progress Note" template:

  • Added code for the last recorded vitals to auto-populate and be displayed.

In the "*NA- Progress Note" template:

  • Added "Fatigue", "Weakness", and "Poor Appetite" to the "General, Constitutional" AutoNote™.
  • Added "Insomnia" to the "Neurological" AutoNote™.

Group Note updates

In the "*Group Note":

  • Added "Provider Location" selectable options of "Telehealth", "Office", and "Community."
  • Added Client "Location" selectable options of "Telehealth", and "In-person."

In the "BHP G- Group Note Report" (*Group Note Associated Report):

  • Added "Provider Location" and Client "Location" to displayed data points.

Version 5.2.0 February 9, 2021

Group Note updates

In the "*G- Group Therapy" note:

  • Added 30, 90, and 240 minute time options to the "Total" drop-down list.

Version 5.0.0 December 18, 2020

Assessment updates

  • Formatting clean up for snapshot and print views.

In the "Additional Demographics" sections:

  • In accordance with CARF 2.B.13.q. added "Do you have any difficulty reading or writing" with a follow up "Please explain" if indicated.

In the "Medical History" sections:

  • Per request of UnitedHealth (Optum), changed "Client reported no known allergies" to "Client reported no known drug, food, or environmental allergies."
  • In the "Medical Conditions" subsection: If pregnancy is indicated, added a follow up checkbox "Receiving Prenatal Care" and a text box for "Provider."

In the "Substance Use History" sections:

  • Per request of UnitedHealth (Optum), changed the prompt language of "Family Mental Health/Substance Use History" to "Include any history of treatment, if applicable, or note an absence of treatment, as well as the overall impact on client."

In the "Mental Status Exam" sections:

  • Added "Congruent" and "Incongruent" to the "Affect" section.

In the "Social History" section of the "Comprehensive Diagnostic Assessment/Biopsychosocial":

  • Due to clarification from UnitedHealth (Optum), edited prompt text to read "REQUIRED FOR ADOLESCENTS. Include history of sexualization, victimization, witnessing and perpetration, patterns of adjustment/maladaption, sexual understanding and outlook, sexual preference and orientation, co-occurring issues."

Group Note updates

  • *Group Note: added the code to populate each client's individual billing data for the session after the note is "Saved & Locked." Added "See Below" as a default display option in the "Billing" field. Codes can still be entered into the "Billing" field if applicable.

Template updates

  • Adjusted spacing in all templates.
  • In accordance with UnitedHealth (Optum) guidelines for CBRS, changed the "Intervention & Education" options in the "PN_CBRS_DATA" "Data AutoNote™ to "Enhancing, Developing, Enhancing and developing, social skills, communication skills, behavior skills, coping skills, basic living skills."
  • Added "Homeless" as an option in the Risk button of the "PN_CL_ASSESSMENT" AutoNote™ series.

Version 4.9.0 October 5, 2020

Assessment updates

In the "Master Treatment Plan":

  • Moved "Discharge/Transition/Aftercare Planning" and "Crisis Plan" sections to display after the "Problem Details" section.

In the "Comprehensive Diagnostic Assessment/Biopsychosocial":

  • Added "Family Treatment Participation" to the "Social History" section which populates to the "Master Treatment Plan" and "Discharge Summary."

Progress Note updates

  • Re-titled "*Med- Progress" to be "*PSY- Progress Note" (Psychiatric Progress Note).

Updated "Data" AutoNote™ as follows (see Figure 8-1):

  • Addressed in session options to include: "Goal", "Problem", and "Objective."
  • Added "Therapeutic Interventions Used in Session", "Response", "Readiness to Change", "Current Functioning", "Treatment Plan Progress" from "Risk and Response" into the "Data" AutoNote™ from the "Response/Risk" AutoNote™.

Updated "Response/Risk" AutoNote™ as follows (see Figure 8-2):

  • Re-titled to "Risk."
  • Moved "Therapeutic Interventions used in Session", "Response", "Readiness to Change", "Current Functioning", "Treatment Plan Progress" from "Risk and Response" AutoNote™ into the "Data" AutoNote™.
  • Changed the label "Risk Assessment" to "High Risk Behavior" for clarity.

Progress Notes Effected: Clinical and Psychiatric.

Figure 8-1. "Data" AutoNote™.

Figure 8-2. "Risk" AutoNote™.

Full mock-up of redesigned progress note (see Figure 8-3):

Figure 8-3 Completed AutoNote™.

Version 4.8.0 September 3, 2020

Assessment updates

In the "Medical History" sections:

  • Added a "Notes/Comments" text-box for both medications and allergies.
  • Fixed an error that prevented the "Eating Habits or Behaviors that may be Indicators of an Eating Disorder, such as Bingeing or Inducing Vomiting" checkbox 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)" checkbox to "Active Withdrawal Symptoms."
  • Removed the bold font style from the "Active Withdrawal Symptoms" checklist.

In the "Discharge Summary":

  • Removed duplicate display of diagnosis.

Version 4.7.0 August 19, 2020

Assessment updates

Discovered and corrected population errors from the "Substance Use History" section of the Comprehensive Diagnostic Assessment/Biopsychosocial:

  • "Substance Use History" table.
  • "Treatment History" table.
  • "Additional Info Regarding Current and/or Past Treatment."
  • "Family Mental Health / Substance Use History."

Additional changes:

  • Removed the "History of Present Illness" section from all assessments.
  • Re-titled the "Chief Complaint" section to "Presenting Condition/HPI" in all assessments.

Version 4.6.0 July 01, 2020

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 to the "Substance Use History" section 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 "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 "Social History" section of the "Comprehensive Diagnostic Assessment":

  • Updated red text prompt to "Significant Relationships, Current Housing & Living Situation" to include "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.

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.

Treatment plan updates

In the "Discharge Summary":

  • Added the "Treatment Planning Participation by Family or Significant Others" section.

  • 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.

In the "Master Treatment Plan":

  • Added the "Treatment Planning Participation by Family or Significant Others" section.

Version 4.5.0 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™.

In the the "CM_PN_DATA" AutoNote™ for the "Case Management Progress Note", corrected coding to allow for selection or free-typing, previously coding was forcing a selection and free-typing.

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.

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.
  • In the "Medical History" section, re-titled checkbox to "No current/past prescriptions or over the counter medications."
  • 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.

  • Added client facing prompt to "Strengths and Preferences."

  • Added client facing prompts to Page 3, "How do the following affect your daily life."

Version 4.4.0 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 Evaluation 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 Note." Added coding that will automatically reflect the date and start time from an associated calendar appointment. 

Added the ability to submit custom options for drop-down selection. 

Minor adjustments for visual improvement (see Figure 3-1).

Figure 3-1. "*Group Note."

Version 4.3.0 January 23, 2020

Comprehensive Diagnostic Assessment updates

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."
  • In accordance with CARF 2.B.13.(b)(c)(d)(e), re-titled "Strengths and Preferences" to "Strengths, Needs, Abilities and Preferences."

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 Evaluation 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.
  • In accordance with CARF 2.B.13.(b)(c)(d)(e), re-titled "Strengths and Preferences" to "Strengths, Needs, Abilities and Preferences."

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 Evaluation."

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 Evaluation."

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

In all "Session Details" AutoNotes™:

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

Version 4.0.0 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 History" section:

  • Added "Other Addictive or Compulsive Behaviors (Non-Substance Use)."

In the "Substance Use History" section:

  • Added Drug Choice 1-3.

In the "Social History" section:

  • Added "Leisure/Recreation."

Comprehensive Diagnostic Assessment updates

In the "Strengths and Preferences" section:

  • Changed red prompt text from "Explain client's strengths / abilities, treatment preferences and barriers to treatment." to "In the client's words: strengths / abilities, treatment preferences such as time availability and barriers to treatment."

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 History" section:

  • Moved "Mental Health/Substance Use Treatment" subsection to the "Substance Use History" section.
  • Added "Other Addictive or Compulsive Behaviors (Non-Substance Use)", this populates from "Portal/Pre-Screen" if used.

In the "Substance Use History" section:

  • Added "Active Withdrawal Symptoms" checkbox series.
  • Added "Longest period of sobriety and anything that helped you accomplish that time."
  • Added "Have you ever attended/participated in support groups."
  • Added "Have you ever overdosed."
  • Added "Have you ever engaged in IV drug use."
  • Added "Have you ever shared needles."
  • Added "How do substances affect your behavior/moods."
  • Added "Have you experienced any negative consequences from your use."

In the "Social History" section:

  • Changed "Basic Living Skills/Other Social Considerations" to "Basic Living Skills/Functional Deficits."
  • Added "Leisure and Recreation."

In the "Risk Assessment" section:

  • Changed "Protective Factors" to "Protective Factors and Natural Supports."
  • Moved "Client Education" section to display after "Readiness to Change" section.

In the "Clinical Formulation" section:

  • Added the option to create "Formulation by Dimension."
  • Content from earlier sections of the "Comprehensive Diagnostic Assessment" will no longer populate into the "Clinical Formulation."

In the "Initial Treatment Plan" section:

  • Removed "Recommended Level of Care" due to its redundancy to the "Clinical Formulation" above.
  • Added an expandable "Referral" table.

Psychiatric Evaluation 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 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.

Substance Use Assessment updates

*With the expansion of the "Substance Use History" section and the addition of the "Formulation by Dimension" in the "Comprehensive Diagnostic Assessment", use of this stand-alone "Substance Use Assessment" has become unnecessary except by preference.*

In the "Strengths and Preferences" section:

  • Changed red prompt text from "Explain client's strengths / abilities, treatment preferences and barriers to treatment." to "In the client's words: strengths / abilities, treatment preferences such as time availability and barriers to treatment."

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."
  • Added "Other Addictive or Compulsive Behaviors (Non-Substance Use)", this populates from early assessments if used.

In the "Recovery/Living Environment" section:

  • 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 "Initial Treatment Plan" section:

  • Added an expandable "Referral" table.

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 "Functional 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

  • Moved "Levels of Care" to appear immediately after "Demographics."
  • Four lines added to "Initial Goals." Each line will auto populate from the "Initial Treatment" section of the assessments, if used.
  • (Comprehensive Diagnostic Assessment, Psychiatric, Substance Use Assessment, History & Physical, Nursing Assessment).
  • New Section added "Safety Plan." Each line will auto populate from the Risk Assessment section of the assessments, if used.
  • (Comprehensive Diagnostic Assessment, Psychiatric, Substance Use Assessment, Nursing Assessment) *The "History & Physical Exam" does not include a "Risk Assessment" section.
  • Moved "Medications" to appear immediately after "Safety Plan."
  • Added a narrative text area in the "Medications" section.
  • Moved "Diagnosis" and "Reason for Changes to Diagnosis" to appear before the "Master Problem List."
  • Removed "Discharge Criteria" due to redundancy to updated "Discharge/Transition/Aftercare Planning."
  • Re-titled the "Discharge/Transition Criteria" section to "Discharge/Transition/Aftercare Planning."
  • Moved "Discharge/Transition/Aftercare Planning" to appear immediately after "Master Problem List."

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)."
  • Moved "Crisis Plan" to appear immediately after "Discharge/Transition/aftercare Planning."
  • Changed "Short-Term Objective" to "Short-Term Objective/Goal."

*The entire "Discharge/Transition/Aftercare Planning" section populates to the "Discharge Summary."

Discharge Summary updates

  • Moved "Levels of Care" to appear immediately after "Reason for Discharge."
  • Added "Date of Last Service."
  • Moved "Discharge Diagnosis" and "Reason for Changes to Diagnosis" to appear immediately after "Initial Problem/Diagnosis."
  • Moved "Medications" to appear immediately after "Reason for Changes to Diagnosis."

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

Added "*O- Missed Service Note."

Version 3.2.0 August 30, 2019

Med/Clinical updates

  • Added the "Risk Assessment" section to "Substance Use Assessment."
  • Added "Drugs of Choice" to "Comprehensive Diagnostic Assessment." 
  • Edits to improve congruency and data flow between "Comprehensive Diagnostic Assessment" and "Substance Use Assessment."
  • Removed "Communicable Disease" follow-up questions from the "Online Application", "Pre-Admission Screen", "Comprehensive Diagnostic Assessment", and "Substance Use Assessment."

Version 3.1.0 August 16, 2019

Assessment updates

Under "Medical History" in the "Pre-Admission Screen", "Comprehensive Diagnostic Assessment" & "Substance Use Assessment":

  • Added a follow-up pain scale to "Acute/Chronic Pain" checkbox. 
  • Added follow-up questions to "Communicable Disease" checkbox. 
  • Added in-line text box to "Other Medical Conditions" checkbox.
  • Added a table to "Medical and Surgical Treatment History." 
  • Added a "Nutrition" screening subsection.

Under "Behavioral Health History" in the "Pre-Admission Screen", "Comprehensive Diagnostic Assessment", and "Substance Use Assessment":

  • Renamed subsection "Abuse/Trauma" to "Abuse, Trauma, Neglect, Exploitation" and edited the red text.

Under "Social History" in the "Pre-Admission Screen", "Comprehensive Diagnostic Assessment", and "Substance Use Assessment":

  • Edited red text in the "Sexual Behavior History" subsection.

In the "Discharge Summary":

  • Added a "Strengths and Preferences" section (populates from the Comprehensive Diagnostic Assessment).

Progress note updates

  • Added "School" as an optional service location.

Appointment type updates

  • The three "Behavioral Health Profile" related appointment descriptions (IND, GRP, CM) now include an asterisk (*).

Version 2.6.3 June 26, 2019

All progress notes

Now automatically display the client's "Date of Birth (DOB)" and "ID #."

Version 2.6.2 June 6, 2019

Med/Clinical updates

The "Substance Use Assessment" was updated to now include a "Mental Status Exam" (see Figure 6-1).

Figure 6-1. 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 May 30, 2019

Med/Clinical updates

The "Comprehensive Diagnostic Assessment" documents "Mental Status Exam" now include the option "Homicidality" in the "Thought Content and Perception" section (see Figure 5-7).

Figure 5-7. "Homicidality" added to the "Mental Status Exam."

Within the "Comprehensive Diagnostic Assessment" the "Initial Goals and Milestones" field was updated to "Initial Goals" to improve clarity (See Figure 5-6). This will still populate into the "Master Treatment Plan" in the same manner as before.

Figure 5-6. "Initial Goals" re-worded.

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" (see Figure 5-5).
  • The "Medical", "Living Arrangements", "Academic/Vocational", "Therapy (Individual, Group, Family, Etc.)", "Other Supports", and "Justification for Continued Treatment" within that section were simplified to "Recommended Services" and "Referrals Needed" (see Figure 5-5).

Figure 5-5. Updated sections and fields in the "Master Treatment Plan" and "Discharge Summary."
  • The "Discharge Criteria", "Discharge / Transition Planning", and "Crises Plan" sections were moved to display together after the "Problem Detail" area and their order was updated (see Figure 5-4).

Figure 5-4. Updated sections in the "Master Treatment Plan."

Progress note updates

The "Data" AutoNote™ has the following updates:

  • Now displays "Goal", "Objectives", and "Intervention and Education" for all progress notes (see Figure 5-3).
  • Goals and objectives now allow for you to select an option or add free text (see Figure 5-3).
  • "Prevention / Collateral Services" now displays (*CL Progress Note only) (see Figure 5-3).

Figure 5-3. Data AutoNote™ Updates.

Within the clinical assessment AutoNote™, the "Mental Status" and "Response/Risk" sections were updated (see Figure 5-1 and 5-2).

Figure 5-2. "Mental Status" AutoNote™ updates.

Figure 5-1. "Response/Risk" AutoNote™ updates.

Version 2.5.0 March 12, 2019

Online/Portal updates

Added "Demographics" to page 1 (see Figure 3-4).

Figure 3-4. "Demographics."

Added "Additional Related Contact" (see figure 3-3).

Figure 3-3. "Additional Related Contact."

Added "Secondary Insurance", also located on the "Pre-Admission Screen" to page 1 (see Figure 3-2).

Figure 3-2. "Secondary Insurance."

Assessment updates

Added "Medication Management" as an "Intervention" option in the behavioral health treatment history table (see Figure 3-1).

Figure 3-1. "Medication Management" as an option.

"Custom Fields" are now available within the profiles.

Version 2.4.9 January 23, 2019

Assessment Updates

Added "Thought Process" to the "Comprehensive Diagnostic Assessment" and "Psychiatric Evaluation" (see Figure 1-6).

Figure 1-6. Added "Thought Process."

Removed red text on the "Pre-Admission Screen" and "Substance Use Assessment" assessments (see Figure 1-5).

Figure 1-5. Removed red text.

Progress Note Updates

Added a text box to the AutoNote™ "*CL - Progress Note" (see Figure 1-4). 

Figure 1-4. Added text box.

Added "Units" to the AutoNote™ "*CM - Progress Note" (see Figure 1-3).

Figure 1-3. Added "Units."

Version 2.4.7 January 7, 2019

Progress note update

The diagnosis was added to the "*CBRS-Progress Note."

Group note update

There is now a prompt to explain the narrative section in the "*Group Note" (see Figure 1-2).

Figure 1-2. New prompt in "*Group Note."

Assessment Update

The "Psychiatric Evaluation" has updated section titles, and reordered sections (see Figure 1-1).

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

Version 2.4.6 December 18, 2018

Assessment Updates

In the "Psychiatric Evaluation":

  • "History of Present Episode" section has been reworded to "History of Present Illness."
  • "History of Past Episodes" section has been reworded to "Psychiatric History."
  • "Developmental, Psychosocial, Sociocultural History", "Sexual History", "Legal History", and "Employment/Military History" sections have been reworded and compressed into one section titled "Personal and Social History."
  • A new section titled "Substance Use History" was added.
  • A new section titled "Medical History" was added and includes allergies and medications.
  • "Substance Use Assessment" had a field updated (see Figure 12-7).

Figure 12-7. "Substance Use Assessment" field updated.

Version 2.4.4 December 10, 2018

Template updates

New "Collaboration of Care Note" (see Figure 12-6).

Figure 12-6. New "Collaboration of Care Note."

"Peer Support" and "Recovery Coaching" assessment templates were updated (see Figures 12-5 to 12-2).

Figure 12-5. Updates to "Peer Support", and "Recovery Coaching" assessment templates.

Figure 12-4. Updates to "Peer Support", and "Recovery Coaching" assessment templates.

Figure 12-3. Updates to "Peer Support", and "Recovery Coaching" assessment templates.

Figure 12-2. Updates "Peer Support", and "Recovery Coaching" assessment templates.

Addition made to the "Recovery Wellness Plan" (see Figure 12-1).

Figure 12-1. Addition to "Recovery Wellness Plan" template.

Version 2.4.2 November 13, 2018

Med/Clinical updates

  • Adjustments were made to the wording and order of the "Mental Status Exam" section in the "Comprehensive Diagnostic Assessment" and "Psychiatric Evaluation."
  • "Basic Living Skills" added to the "Social History" section.
  • Added allergies and a brief "Mental Status Exam" 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 11-1).

Figure 11-1. View "Med/Clinical" most recent changes.

Version 2.3.0 October 30, 2018

Assessment updates

  • Simplified "Risk Assessment" and "Clinical Formulation and Medical Necessity" sections.
  • "Behavioral Health History" section received wording edits.
  • Unmarked checkboxes no longer appear on snapshot.

The "Substance Use Assessment" has had significant edits to the "Clinical Formulation and Medical Necessity", and "ASAM Dimension" sections. These edits are intended to bring the document into closer alignment with the "Comprehensive Diagnostic Assessment."

Version 2.2.2 October 11, 2018

Group note updates

Wording and formatting has been updated.

Med/Clinical updates

  • "Behavioral Health History" section received wording edits.
  • Medical necessity questions were added to the "Clinical Formation."
  • A section ordering fix was implemented.

Version 2.2.0 October 4, 2018

Template updates

  • Template titles now begin with department abbreviation. For example, "CL-" is "Clinical."
  • "PSRC" (Peer Support/Recovery Coaching) templates have been split into separate documents, "PS" as "Peer Support or "RC" as "Recovery Coaching."
  • Added initial discharge content to the "PS- Recovery Wellness Plan" and the "RC- Recovery Wellness Plan."
  • Added a "Case Management" assessment titled "*CM-Assessment."

Group Note updates

  • Removed days of the week.
  • Removed extra group box.
  • Added billing.
  • Added risk.
  • Added next appointment.

Version 2.1.0 September 28, 2018

Progress note/template updates

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 September 14, 2018

Progress note updates

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 respective Optum audit tools and new (July 2018) Level of Care Guidelines.

Version 2.0.0 September 6, 2018

Progress note updates

  • "*C-Progress Note, Clinical" has had some minor formatting edits. 
  • "*CM-Progress Note, Case Management" has had formatting edits and significant content updates.



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