Behavioral Health Profile Updates

Profile Version Updates


Version 4.0.0 - 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 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".

CDA 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, /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)- 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 CDA 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 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.

SUA Updates

*With the expansion of the Substance Use History section and the addition of the Formulation by Dimension in the CDA, use of this stand-alone SUA 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)- 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.

H & P Exam Updates

Completely redesigned to utilize existing standard sections, and have those sections populate forward where appropriate.

  • Added the standard Medical History section, programmed to populate data forward from earlier assessments.
  • Added the standard Initial Treatment Plan section.

Nursing Assessment Update

New assessment for the profile designed to utilize existing standard sections, and have those sections populate forward where appropriate.

  • Includes the standard Medical History section, programmed to populate data forward from earlier assessments.
  • Includes the standard Substance Use History section,  programmed to populate data forward from earlier assessments.
  • Includes the standard Medical Review of Systems section- does not populate.
  • Includes a Function Screen.
  • Includes the standard Risk Assessment section- does not populate. If a safety plan  is indicated in this section it will populate to the Master Treatment Plan.
  • Includes the standard Initial Treatment Plan section.

Master Treatment Plan updates

  • Moved "Levels of Care" to appear immediately after Demographics."
  • 4 lines added to "Initial Goals". Each line will auto populate from the Initial Treatment section of the assessments, if used.
  • (CDA, Psychiatric, SUA, H & P, Nursing Assessment).
  • New Section added "Safety Plan",  Each line will auto populate from the Risk Assessment section of the assessments, if used.
  • (CDA, Psychiatric, SUA, Nursing Assessment) *The H & P 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 - 08/30/2019

Med/Clinical updates

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

Version 3.1.0 - 08/16/2019

Assessment updates

Under Medical History in the Pre-Screen, CDA & SUA:

  • 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-Screen, CDA & SUA:

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

Under Social History in the Pre-Screen, CDA & SUA:

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

In the Discharge Summary:

  • Added a "Strengths and Preferences" section (populates from the CDA).

Progress note updates

  • Added "School" as an optional service location.

Appointment type updates

  • The 3 BHP-related appointment descriptions (IND, GRP, CM) now include an asterisk (*).

Version 2.6.3 - 06/26/2019

All progress notes

Now 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". (see Figure 1-22).
  • 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 1-22).

Figure 1-22. 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 1-23).

Figure 1-23. 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 1-24).
  • Goals and objectives now allow for you to select an option or add free text (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

Online/Portal updates

Added "Demographics" to page 1 (see Figure 1-16).

Figure 1-16. Demographics.

Added "Additional Related Contact" (see figure 1-17).

Figure 1-17. Additional Related Contact.

Added "Secondary Insurance", also located on the Pre-Screen to page 1 (see Figure 1-18).

Figure 1-18. Secondary Insurance.

Assessment updates

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

Figure 1-19 Medication Management as an option.

Custom Fields are now available within the profiles.


Version 2.4.9 - 01/23/2019

Assessment Updates

Added "Thought Process" to the CDA and PE (see Figure 1-12).

Figure 1-12. Added "Thought Process".

Removed red text on the Pre-Screen and SUA assessments (see Figure 1-13).

Figure 1-13. Removed Red Text.

Progress Note Updates

Added a text box to the autonote "*CL - Progress Note" (see Figure 1-14). 

Figure 1-14. Added Text box.

Added "Units" to the autonote "*CM - Progress Note" (see Figure 1-15).

Figure 1-15. Added "Units".

Version 2.4.7 - 01/07/2019

Progress note update

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

Group note update

There is now a prompt to explain narrative section in the "*Group Note" (see Figure 1-10).

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

Assessment Update

The Psychiatric Evaluation has updated section titles, and reordered sections (see Figure 1-11).

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

Version 2.4.6 - 12/18/2018

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 1-9).

Figure 1-9. SUA field updated.

Version 2.4.4 - 12/10/2018

Template Updates

New Collaboration Note (see Figure 1-2).

Figure 1-2. New Collaboration Note.

Peer Support and Recovery Coaching Assessment templates were updated. (see Figures 1-3 to 1-6).

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.

Addition made to the "Recovery Wellness Plan" (see Figure 1-7).

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

Version 2.4.2 - 11/13/2018

Med/Clinical updates

  • Adjustments were made to the wording and order of the "Mental Status Exam" section in the CDA and Psych Eval.
  • "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 1-1).

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

Version 2.3.0 - 10/30/2018

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 SUA 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 CDA.


Version 2.2.2 - 10/11/2018

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 - 10/04/2018

Template Updates

  • Template titles now begin with department abbreviation. For example, "CL-" Clinical.
  • PSRC (Peer Support/Recovery Coaching) templates have been split into separate documents, PS (Peer Support) or RC (Recovery Coaching).
  • Added initial discharge content to the PS and RC Recovery Wellness Plan.
  • Added a Case Management Assessment. *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 - 09/28/2018

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 - 09/14/2018

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 - 09/06/2018

Progress Note Updates

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



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