This article provides a guide on how to locate and effectively use the Med/Clinical documentation features within BestNotes.

Permissions Required

No specific BestNotes permissions are required.

Visual Tutorial

This video tutorial covers the following topics:

• 0:05 Navigate to Med/Clinical
• 0:48 Documentation sets
• 1:33 Pre-Screen Intake Assessment
• 3:07 CDA/BPS Comprehensive Diagnostic Assessment or Biopsychosocial
• 3:55 CDA/BPS Diagnosis Tool
• 5:54 Master Treatment Plan
• 6:10 Master Treatment Plan Diagnosis Tool
• 8:07 Master Problem List
• 9:04 Treatment Plan Review

Using Med/Clinical Documentation Features

The Med/Clinical section in BestNotes allows you to access and manage various documentation sets essential for client care. Follow these steps to understand and utilize its features:

1. Navigate to Med/Clinical
   Locate and open the Med/Clinical section within BestNotes to begin accessing documentation.
2. Understand Documentation Sets
   Familiarize yourself with the different documentation sets available, which are collections of forms and assessments used for various clinical purposes.
3. Complete a Pre-Screen Intake Assessment
   Utilize the Pre-Screen Intake Assessment to gather initial information about a client before a comprehensive evaluation.
4. Conduct a CDA/BPS Comprehensive Diagnostic Assessment or Biopsychosocial
   Perform a Comprehensive Diagnostic Assessment (CDA) or Biopsychosocial (BPS) to conduct a thorough evaluation of the client's medical, psychological, and social history.
5. Use the CDA/BPS Diagnosis Tool
   Employ the Diagnosis Tool within the CDA/BPS to assist in formulating and documenting a client's diagnosis based on assessment findings.
6. Develop a Master Treatment Plan
   Create a Master Treatment Plan to outline the client's goals, objectives, and interventions for their treatment journey.
7. Utilize the Master Treatment Plan Diagnosis Tool
   Integrate the Diagnosis Tool within the Master Treatment Plan to ensure diagnoses are consistently linked to treatment goals.
8. Manage the Master Problem List
   Maintain an up-to-date Master Problem List that details all identified issues and concerns for the client, guiding ongoing care.
9. Perform a Treatment Plan Review
   Regularly review the Treatment Plan to assess progress, make necessary adjustments, and ensure the plan remains relevant to the client's evolving needs.