An electronic health record (EHR) must accommodate the need to document a large assortment of information — everything from the services delivered to a client for continuity of care and contract oversight, to the client’s response to treatment, to detailed information about billing.
The Clinical Management for Behavioral Health Services (CMBHS) system includes multiple note types to ensure that all the fields needed by the user are available and to differentiate between notes for clinical use and those for the non-clinical aspects of service delivery. Each note is labeled as to type and is visible from the Client Document List on the Client Workspace, making it easy to find specific note types.
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CAUTION: If you have made a serious documentation error in CMBHS that has or may result in the breach of a client’s rights to privacy, report the event to your supervisor, your Local CMBHS Security Administrator, or other person designated by your agency and contact the CMBHS Help Line at 1-866-806-7806. |
There are several note types in CMBHS that you can use to document information in the client’s health record. The note types in CMBHS are similar to those used in other systems, differentiating primarily between notes for clinical information and notes not related to the clinical aspects of service delivery.
Information about treatment and therapeutic interventions are recorded in CMBHS using a Progress Note, while other information that is not about direct clinical subjects is documented as an Administrative Note. Educational services are documented using the Psychoeducational Note.
A Life Event Note is a non-billable note for clients receiving SUD services or services at any Prevention/Intervention (P/I) location that provides Pregnancy and Postpartum Intervention (PPI) services. This note is used primarily by Case Managers at PPI and SUD locations.
In CMBHS, multi-client and single client note functions are available. Multi-client notes are used only for educational services when the same note can be entered into the record of each client who participated. It cannot be used for therapeutic services.
The multi-client and single client note functions are accessed from different toolbars. Single client notes are accessed from the Client Services Toolbar at the left side of your screen, while multi-client notes are accessed from the Administrative Toolbar at the top of the screen. When completed, notes appear on the document list in the Client Workspace.
The Treatment Plan Verfication deployment in CMBHS implemented a change to support the Texas Administrative Code (TAC) 448. The TAC requires the documentation of a Treatment Plan in a client's file within five service days of beginning a service.
When a Progress or Psychoeducational Note is documented without a Treatment Plan, CMBHS will warn you of the requirement for the document to be Closed Complete status within the first five client service days.
In addition, if a client's SUD Assessment is more than 30 days old, you will not be able to create an Initial or Update Treatment Plan for that client without first creating or updating an assessment.
Service days are when a service has been provided for a client. In Residential services, these are calendar or consecutive days. In Outpatient, these are days when the counselor or counseling staff provided a service, such as an Individual Counseling or Group Counseling session. These days are not typically consecutive days, since a client may only attend counseling a few days a week.
A Progress Note is used to document the delivery of a service to a client, the client’s response, and progress towards goals identified in the treatment plan. The Progress Note is also the place to address clinical observations of the counselor, collateral contacts with clinical relevance, and other clinically significant events.
When you save a Progress Note in Closed Complete or Ready for Review document status, by CLICKING on the Save button, CMBHS validates all the data fields looking for errors.
A Progress Note cannot be created unless it is within the Begin and End Date for the service selected.
When you attach a Progress Note to a Treatment Plan Objective, CMBHS displays a list of the Objectives in the client’s Treatment Plan that have the current status of In Progress.
Only staff in the Performed By field and a staff member with the clinical supervisor role can edit a Progress Note.
Only a Progress Note in Draft status can be deleted.
You can access the Progress Note page from two places in CMBHS.
From the Clinician or Case Manager Workspace:
From the Client Workspace:
The Progress Note screen is dynamic and the fields that display will depend upon the Progress Note type. The Progress Note types are:
Performed By (Required)
This field is used to document the name of the staff who provided the service to the client.
This field will default to the staff member creating the Progress Note. If you are documenting services that you provided to the client, your name should be displayed.
If you are documenting a progress note about services provided by another staff, then you must make a change in this field. Remove your name (if it displays) by selecting the name of the staff from the dropdown list.
Contact Type (Required)
Use this field to document the type of contact you had with the client.
The answer choices are:
Service Location (Required)
This field is used to document the location where the service was provided to the client. Select the correct location from the drop down list. The options are:
Service Location Type- If the Treatment Plan and Progress Note Type is Counseling, and Contact Type is either Telehealth or Telephone, a dropdown menu will be displayed:
Service Date (Required)
In this field, document the date that the service was provided to the client.
Enter the date in the text box by entering eight numbers (mmddyyyy) and CMBHS will put them on the correct date format (mm/dd/yyyy), or you may enter the forward slash marks yourself.
Start Time (Required)
This is the place to document the time that service delivery to the client began.
TYPE the time into the text box, entering the four numbers (hhmm) of the time (putting a zero before single digits), and CMBHS will put them in the correct time format (hh:mm), or you may enter the punctuation yourself.
End Time (Required)
This is the time the services to the client stopped.
Put the time in the text box by entering four numbers (hh:mm) and CMBHS will put them in the correct time format (hh:mm), or you may enter the puncturation yourself.
NOTE: The Begin and End time you document for a service should reflect the amount of time you spent with a client; preparation and documentation time may not be included.
Duration (Required)
Add Service Type
Click this button to document a type of service in the Progress Note. The dropdown list will display all service types open for the client.
The Billable checkbox is used to indicate if the service provided is billable to HHSC.
The Service Description will display a list appropriate for the note type and Service Type. Select the Service Description from the dropdown list. If Other is selected, a text box will display to explain the meaning of Other.
The Service Units will be calculated from the Duration.
Billing Unit (Required)
Topic Addressed (Required for Group Notes)
Session Narrative (Required)
This field is used to document the client’s response to services — information that will assist other clinicians/providers in delivering the safest, most effective services to the client. This may also include other information that must be documented as required by law or contract.
Your organization and others may require that you document the narrative part of your progress note using a certain format. CMBHS does not require a specific format and allows you to enter text using any format.
If note type is Nursing, after the session narrative a Vital Signs section will display with fields for the following measurements:
If the note type is Detoxification Monitoring Note, in addition to the vital signs section, the signs and symptoms will display with the following fields:
Dropdown options:
0 – Not Present
1 – Very mild
2 – Mild
3 – Moderate
4 – Moderately Severe
5 – Severe
6 – Very Severe
Dropdown options:
0 – Not Present
1 – Very mild
2 – Mild
3 – Moderate
4 – Moderately Severe
5 – Severe
6 – Very Severe
Dropdown options:
0 – Not Present
1 – Very mild
2 – Mild
3 – Moderate
4 – Moderately Severe
5 – Severe
6 – Very Severe
Dropdown options:
0 – Not Present
1 – Very mild
2 – Mild
3 – Moderate
4 – Moderately Severe
5 – Severe
6 – Very Severe
Dropdown options:
0 – Not Present
1 – Very mild
2 – Mild
3 – Moderate
4 – Moderately Severe
5 – Severe
6 – Very Severe
Dropdown options:
0 – none
1 – very mild itching, pins and needles, burning, numbness
2 – mild itching, pins and needles, burning or numbness
3 – moderate itching, pins and needles, burning or
numbness
4 – moderately severe hallucinations
5 – severe hallucinations
6 – extremely severe hallucinations
7 – continuous hallucinations
Dropdown options:
0 – not present
1 – very mild sensitivity
2 – mild sensitivity
3 – moderate sensitivity
4 – moderately severe hallucinations
5 – severe hallucinations
6 – extremely severe hallucinations
7 – continuous hallucinations
Dropdown options:
0 – not present
1 – very mild sensitivity
2 – mild sensitivity
3 – moderate sensitivity
4 – moderately severe hallucinations
5 – severe hallucinations
6 – extremely severe hallucinations
7 – continuous hallucinations
Dropdown options:
0 – Not Present
1 – Very mild
2 – Mild
3 – Moderate
4 – Moderately Severe
5 – Severe
6 – Very Severe
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Dropdown options:
0 – None
1 – Mild
2
3 – Moderate
4
5 – Extreme
6
Radio buttons for Absent or Present
Radio buttons for Absent or Present
Radio buttons for Absent or Present
Radio buttons for Absent or Present
Select a Document Status from the dropdown list before saving your documentation.
The statuses available to you will depend on your role(s). Click here to view Page Rights in CMBHS according to Roles.
The Progress Note Document Status choices are:
Performed By (Required)
This field is used to document the name of the staff who provided the service to the client.
This field will default to the staff member creating the Progress Note. If you are documenting services that you provided to the client, your name should be displayed.
If you are documenting a progress note about services provided by another staff, then you must make a change in this field. Remove your name (if it displays) by selecting the name of the staff from the dropdown list.
Contact Type (Required)
Use this field to document the type of contact you had with the client.
The answer choices are:
Service Location (Required)
This field is used to document the location where the service was provided to the client. Select the correct location from the drop down list. The options are:
Service Date (Required)
In this field, document the date that the service was provided to the client.
Enter the date in the text box by entering eight numbers (mmddyyyy) and CMBHS will put them on the correct date format (mm/dd/yyyy), or you may enter the forward slash marks yourself.
Select Activities
A list of Activities will be displayed. The select activities section can be expanded + or collapsed – by using the desired icon.
Activity Groups include:
Basic Medical Attention - Provided In-house
Basic Medical Attention - Referral
Employment/Educational - ADA Issue
Employment/Educational - Educational (GED)
Employment/Educational - Unemployment Benefits Claims
Employment/Educational - Vocational
Family Services - Child Care
Family Services - Domestic Violence
Family Services - Family Planning
Family Services - Parenting Education
Financial Assistance - Food Assistance
Financial Assistance - Health Insurance Costs
Financial Assistance - Medical Services Fees
Financial Assistance - Social Security (for SSI or SSDI)
Financial Assistance - Veterans Programs
HIV AIDS Services - AIDS Service Organizations (ASO)
HIV AIDS Services - HIV Education
HIV AIDS Services - HIV Intervention Counseling
HIV AIDS Services - HIV Motivational Counseling
Medical Benefits/Care - Dental
Medical Benefits/Care - Enrollment in Medicaid/Medicare
Medical Benefits/Care - HIV Primary Medical Care
Medical Benefits/Care - Hospice
Medical Benefits/Care - Medical Supplies
Medical Benefits/Care - Nutritional Services
Medical Benefits/Care - Other Medical Services/Treatment
Medical Benefits/Care - Pediatric Coordination/Care
Medical Benefits/Care - Prenatal Health
Medical Benefits/Care - Prescriptions
Medical Benefits/Care - Reproductive Health
Medical Benefits/Care - Tobacco Cessation
Medical Benefits/Care - Wellness Programs
Medication Assisted Recovery Support In-House - 48-Hour Shelter
Medication Assisted Recovery Support In-House - Employment
Medication Assisted Recovery Support In-House - Housing
Medication Assisted Recovery Support In-House - Recovery coaching
Medication Assisted Recovery Support Referral - Employment
Medication Assisted Recovery Support Referral - Housing
Medication Assisted Recovery Support Referral - Recovery coaching
Medication Assisted Therapy (MAT) - Induction In-House
Medication Assisted Therapy (MAT) - Medication Storage Material Received
Medication Assisted Therapy (MAT) - Referral
Medication Disposal - Material Received
Medication Received - Naloxone
Mental Health - Bereavement Planning
Mental Health - Family Counseling
Mental Health - Mental Health Services
Other - Child Collateral Needs
Other - Child Legal Coordination
Other - Clothing
Other - Housing (Including HOPWA)
Other - Legal Services
Other - Other Non-Substance Abuse Services Accessed
Other - State ID
Other - Transportation
Overdose Prevention Education - Administration Training
Primary Prevention - Primary Prevention Services
Smoking Cessation - Smoking Cessation Services
Support Groups - Family/Significant Other Support Group
Support Groups - HIV Support Group
Support Groups - HIV and Substance Abuse Support Group
Support Groups - Mommies Group
Support Groups - Postpartum Group
Support Groups - Substance Abuse Support Group
The Case Management program staff will select the activity that was conducted for and/or with the client by selecting the “Select” checkbox.
Activities Utilized
Each activity selected will be displayed in a grid below the activity list for the Case Management Program staff to document:
Substance Abuse
The Substance Abuse section is used to document whether the client has received any Substance Abuse Treatment Services indicated by selecting either the YES or NO radio button. If NO is selected there is no other information needed. If YES is selected, the system will display a NEW SERVICE button. When the NEW SERVICE button is selected, the system will display:
Session Narrative Field (required)
This field is used to document the client’s response to services — information that will assist other clinicians/providers in delivering the safest, most effective services to the client. This may also include other information that must be documented as required by law or contract.
Your organization and others may require that you document the narrative part of your progress note using a certain format. CMBHS does not require a specific format and allows you to enter text using any format.
Document Status (Required)
Select a Document Status from the dropdown list before saving your documentation.
The statuses available to you will depend on your role(s). Click here to view Page Rights in CMBHS according to Roles.
The Progress Note Document Status choices are:
An Administrative Note is used to document non-clinical events and information that must be documented in the client’s health record, often as required by contract or regulation. Administrative Notes may be documented for a single client from the Client Services toolbar.
Select Service Documentation > Administrative Note (Single Client) to begin documenting this type of note. Fill in the dropdown lists and text boxes to complete the note. Don’t forget to click the Save button.
In CMBHS, Administrative Notes may be documented for a single client or for multiple clients. To use the single-client note function, you must be in the record of the client you are documenting. The multi-client function puts the same note in the health record of each client the user selects from a list of active clients at the location.
The Life Event Note (LEN) addresses pregnancy and birth for individual clients at Substance Use Disorder (SUD) treatment locations or Pregnancy and Postpartum Intervention (PPI) Prevention/Intervention (P/I) locations.
A Life Event Note does not require an Open Case or Close Case episode in order to be documented and multiple Life Event Notes may be entered for the same client. These notes are gender and age neutral.
A blank form for the Life Event Note is available from the Administrative Services Toolbar > Data > Print Blank Form — this can be used to report a life event if CMBHS is temporarily unavailable.
The Laboratory/Test Results function in Clinical Management for Behavioral Health Services (CMBHS) allows documentation of the results of laboratory and other medical tests in a client’s health record.
The Laboratory/Test Results function is not billable from the Results location. If they are billable in CMBHS, Laboratory and Test Results are billed using the Progress Note type Other. Click here to see more information about Progress Notes.
This function is available to all service providers that deliver client services and that need to document this information.
The individual CMBHS user must have a role that allows documentation in the client record and specifically the Lab/Test results page. Click here for a list of Roles and Page Rights in CMBHS.
For any test type you select to document, you must provide all required information for that test in order to Save.
To document in the Lab/Test Results page, you must be in the Client Workspace.
From the Client Services Toolbar on the left side of the page, hover over Service Documentation. A menu will drop down. Move towards the bottom of the list and CLICK on Lab/Test Results.
The Lab/Test Results page will open.
Select the type of Lab/Test from the dropdown list. The list includes:
Complete all the data fields that are applicable to the test type you have selected and the client.
After you have finished documenting the Lab/Test Results, CLICK on the Save button, at the lower right corner of the screen. You will receive a Successfully Saved Message. CLICK on OK.
NOTE: If you made an error or choose not to save your documentation, you can CLICK on the Cancel button. This will delete your documentation from the client record. This will only work if you have not yet pressed the Save button.
To create an Administrative note for multiple clients, hover your mouse pointer over Provider Tools in the Administrative Toolbar at the top of your screen and select Administrative Note (Multi-Client).
In the Note Detail area of the screen, choose the Administrative Note Type from the dropdown list.
Next, complete the Activity Date text box, and click or leave open the Show only open services checkbox.
Select a Service Type from the dropdown list.
Type the contents of the Administrative Note in the Narrative text box. The number of characters you may type is not limited, and there is no required format. The Narrative field is required.
In the Performed By dropdown list, your name as the documenter should be pre-filled. If you are documenting for someone else (i.e., you do not have organizational responsibility or you did not witness an event), choose that person’s name from the dropdown list. When you click on that person’s name, your name will be replaced in the Performed By field.
Using the single or double up and down arrows between the upper and the lower Clients list boxes, move clients to be included for this note from the upper box to the lower box. To move one client, CLICK on the name to highlight it and click the single down arrow. To choose multiple clients, hold down the Ctrl key while you click the names. To move all clients listed between the upper and lower lists, use the double arrows.
Next, choose a document status of Closed Complete, Closed Incomplete, Draft, or Ready for Review from the Document Status dropdown list.
Click on the Save button, and if you have completed all fields correctly, you will be notified that the Administrative Note has been saved. CMBHS will display a list of the clients in the note.
Clinical Management for Behavioral Health Services (CMBHS) provides users a way to document service provision to a single client and to multiple clients. The multiple client function allows the provider to write one note that will be placed in the health records of multiple clients.
This function is used when each client received the same service (e.g., all attended a class on accessing community resources or received the same medication) and there is no need to document any additional individualized information.
The multi-client note can be used to bill for some services. Consult your HHSC Contract and the Texas Administrative Code for more details regarding documentation of service delivery.
If there is a need to document additional clinical information for a client, a Progress Note can be written in a client’s record and marked as non-billable, assuming the multi-client note was used to bill for the applicable services.
The Clinical Management for Behavioral Health Services (CMBHS) system provides the user ability to document a wide array of medication-related services documentation. This includes providing medications directly to clients, prescribing medications, or documenting and viewing a client’s medication history.
The CMBHS system is not designed to substitute for the clinical judgment of a licensed professional. It is critical to client safety that a licensed professional verify the accuracy and safety of all medication orders, checking for drug allergies, interactions, therapeutic duplications, and appropriate dosing.
Click here for more information on medication services.
The psychoeducational note is used to document the provision of educational services, content, and attendance. Psychoeducational notes are not used to document group counseling sessions. Psychoeducational notes are billable only when outpatient is selected as the Service Type and an education service is selected from the Service Description dropdown list.
The psychoeducational note from the Client Services Toolbar allows the user to write one note that can be added to the health record of a single client. (The psychoeducational notes function for multiple clients is accessed from the Administrative Functions Toolbar. Click here for more information about these functions.)
From the Client Services Toolbar, hover over Service Documentation and select Psychoeducational Note (Single Client).
The Progress Note page is displayed.
The Note Detail fields are:
Progress Note Type – This field will be pre-filled with "Psychoeducational" and cannot be edited.
Performed by – Select the name of the staff member who conducted the psychoeducational session.
Contact Type – Use this field to document the type of contact you had with the client.
Answer choices are:
Service Location – This field is used to document the location where the service was given to the clients.
Choices are:
Funding Source – Select the appropriate funding source for billing.
Service Date – Document the date that the service was provided to the client in this field. You can type in the 8 numbers for the date, mmddyyyy (e.g., 03082019) and CMBHS will format the date as mm/dd/yyyy (03/08/2019). Or you can type the forward slashes yourself.
Start Time – Enter the start time of the session. You can enter four numbers for the time, 0900, and CMBHS will format the time as 09:00. Or you can enter 09:00.
End Time – Enter the end time of the session. You can enter four numbers for the time, 0900, and CMBHS will format the time as 09:00. Or you can enter 09:00.
Duration – Calculated from start time to end time. Field is not editable. Duration is displayed in hours and minutes.
Add Service Type Button – Selecting this button will display the Service Type, Billable, Service Description, Service Units, Topics Addressed, and Session Narrative fields.
Service Type – Dropdown list of service types. Select appropriate service type for the client.
Billable Checkbox – When a billable service description is selected, a checkmark will populate the billable field.
Service Description – This dropdown list will be determined by the Service Type. Select the appropriate service description for the session conducted. CLICK ON your choice to highlight and select a service.You may pick only one.
Service Units – Defaults to the calculation based on the start time and end time.
Topics Addressed – Enter topics addressed during session. This is a required field for group notes.
Session Narrative – This field is used to document the client's response to services — information that will assist other clinicians/providers in delivering the safest, most effective services to the client — and/or other information that must be documented as required by law or contract.
Your organization may require that you document the narrative part of your progress note using a certain format. CMBHS does not require a specific format and allows you to enter text using any format.
The following are recommended formats that can be used for the session narrative:
S.O.A.P.
• Subjective – client's observations or thoughts, client's direct
statements
• Objective – counselor's observation during session
• Assessment – the counselor's understanding of the problem
and assessment results
• Plans – goals, objectives and strategies reflective of client's
needs during the assessment
C.A.R.T.
• C=client condition
• A= what action did the counselor do in response to client
condition
• R=client response to treatment plan
• T=how response related to treatment plan
B.I.R.P.
• Behavior
• Intervention
• Response
• Plan
D.A.P.
• Describe (the facts of the session)
• Assess (Evaluate client’s treatment progress toward meeting
his/her goals)
• Plan (Document what is going to happen next)
You are not limited on the number of characters you may enter in this text box.
To enter text into the text box, CLICK IN the box and begin typing.
Document Status – select the appropriate document status. This is the end of the single-client psychoeducational note.
A Progress Note is used to document the delivery of a service to a client, the client’s response, and progress towards goals identified in the treatment plan. The Progress Note is also the place to address clinical observations of the counselor, collateral contacts with clinical relevance, and other clinically significant events.
A Progress Note is a permanent record in the client's file and cannot be deleted once it is saved in Closed Complete status.
A note can be changed or edited, but the original version is maintained in the record and the new version is marked as Version 2 and so on.
When you save a Progress Note in Closed Complete status, by CLICKING on the Save button, CMBHS validates all the data fields looking for errors.
A Progress Note cannot be created unless it is within the Effective date and due date for the service selected in the Closed Complete IRP.
For Client who has active Medicaid, the system will look for TMHP authorization number while saving the Progress Note and the services will be paid by Medicaid.
For Client who do not have active Medicaid, the system will not look for TMHP authorization number while saving the Progress Note and the services will be DSHS/GR funds.
Provider Agency staff can create Progress Note only if the Client is Enrolled in the HCBS-AMH program.
Recovery Manager staff can create Progress Note when the Client’s Enrollment status is Enrolled or Suspension.
Both Recovery Management Entity Staff and Provider Agency staff cannot create Progress Note if the client’s Enrollment status is Disenrolled.
Only staff in the Performed By field and a staff member with the edit role can edit a Progress Note.
Only a Progress Note in Draft status can be deleted.
The Progress Note screen is dynamic and the fields that display, will depends on the location signed in by the users. Below are the following fields displayed on the Progress Note.
Progress Note Type Field - This is a drop-down field with 2 options. Which are given below:
Performed By (Required)-
This field is used to document the name of the staff who provided the service to the client.
User/Staff should select their name from the drop-down list, if you have provided the services to the client.
If you are documenting a progress note about services provided by another staff, then you must select another staff name from the dropdown list.
Contact Type (Required)-
Use this field to document the type of contact you had with the client.
The answer choices for Provider Agency Progress Note Type are:
Face to Face Client – The provider provided services to the client in person.
Telehealth Client – A service provided by a physician (or other health care provider within the scope of the provider's license or certification) for diagnosis, consultation, treatment, or transfer of data, using interactive audio or video, still-image capture, or any other technology that facilitates access to health care services or medical specialty expertise.
Telephone – The Provider and recipient have contact by phone.
The answer choices for Recovery Management Entity Progress Note Type are:
Face to Face Client – The Provider provided services to the client in person.
Face to Face Collateral – The Provider provided service to any of the client’s representative.
Telehealth Client – A service provided by a physician (or other health care provider within the scope of the provider's license or certification) for diagnosis, consultation, treatment, or transfer of data, using interactive audio or video, still-image capture, or any other technology that facilitates access to health care services or medical specialty expertise.
Telehealth Collateral – Telehealth service provided to the client’s representative.
Telephone Client– The Provider and Client have contact by phone.
Telephone Collateral – Services provided to client’s representative by Telephone.
Service Location (Required)-
This field is used to document the location where the service was provided to the client. Select the correct location from the dropdown list. The options are:
Home
Custodial Care Facility
Office
Group Home
Assisted Living Facility
Temporary Lodging
Telephone
Custodial Care Facility
In-patient Psychiatric Facility
Place of Employment
Prison/Correctional Facility
Mobile Unit
Not Applicable
Other Unlisted Facility/Place of Service
Other Service Location (Required)- When Other Unlisted Facility/Place of service is selected, “Other Service Location” text box will be provided to explain.
Service Date (Required)-
In this field, document the date that the service was provided to the client.
Enter the date in the text box by entering eight numbers (mmddyyyy) and CMBHS will put them on the correct date format (mm/dd/yyyy), or you may enter the forward slash marks yourself.
Start Time (Required)-
This is the place to document the time that service delivery to the client began.
Type the time into the text box, entering the four numbers (hhmm) of the time (putting a zero before single digits), and CMBHS will put them in the correct time format (hh:mm), or you may enter the punctuation yourself.
End Time (Required)-
This is the time the services to the client stopped.
Put the time in the text box by entering four numbers (hh:mm) and CMBHS will put them in the correct time format (hh:mm), or you may enter the punctuation yourself.
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NOTE : The Begin and End time you document for a service should reflect the amount of time you spent with a client; preparation and documentation time may not be included. |
Duration
This field will pre-fill automatically using the Start Time and End Time information you entered in the fields above. Duration is displayed in minutes.
Add Service Type Button -
Click this button to document a Service Type, Service Description in the Progress Note.
Service Type (Required) –
This field will display all service types selected in a Closed Complete IRP for the start and end dates selected or Entered.
Service Description (Required)-
This field will display the description of the service type selected along with their procedure codes and Modifiers.
Select the Service Description from the dropdown list. If Other is selected, then the system will display a text box “Other Service Description” to explain the meaning of Other.
Note:
In case of Medicaid client and Non -Medicaid Client, if the ‘Contact Type’ is selected as ‘Face to Face’, then select any value other than ‘Telephone’ from Service Location drop-down and select a regular ‘Service Description’ for selected Service Type to save the Progress Note.
If the Contact Type is selected as ‘Telephone/Telehealth’, then select ‘Telephone’ as the Service Location and Service Description with modifier FQ or 95 for the selected Service Type.
Other Service Description (Required)- This field will be displayed when the user selects Other from the service description drop down field. The system will default the billable field as “Not Billable”.
Billable - The system will auto Check this check box as Billable, when user selects the Service Description. If the Service description selected as Other then, the system will display it as Not Billable.
This can be editable, and user can uncheck the box if no service has been provided for the service type selected.
Dollar Amount/Service Units - The system will auto populate the calculated value based on the service type, service description, Start & End time of service and Duration.
This will be an editable field. However, the system will not let the user save the progress Note, if the units entered are more than the authorized units.
The system will display a read only authorized value from the Closed Complete IRP on the right side of the Dollar Amount/Service units field.
Billing Units - This field will display the different billing units based on the service type selected. For Example: Hour, Cost, Per Day etc.
This field is view only and cannot be changed by the user.
Goals - This section will be displayed, if there are any Goals added to the Closed Complete IRP.
If there are any Goals in the Closed Complete IRP then, the system will display them under this section and make this section as required. User should select at least one Goal to save the document in Closed Complete.
This section will have Select All Goals and Unselect All Goals Tabs, which will help the user select multiple/ list of goals at a time and vice versa.
Objectives - This section will be displayed, if there are any Objectives added to the Closed Complete IRP.
If there are any Objectives in the Closed Complete IRP then, the system will display them under this section and make this section as required. User should select at least one Objective to save the document in Closed Complete.
This section will have Select All Objectives and Unselect All Objectives Tabs, which will help the user select multiple/ list of goals at a time and vice versa.
Topic Addressed/Modality (Required for Group Notes)
Document the topic that was discussed with the client(s) (and/or service recipients) into the text box.
Session Narrative (Required)
This field is used to document the client’s response to services — information that will assist other clinicians/providers in delivering the safest, most effective services to the client. This may also include other information that must be documented as required by law or contract.
Your organization and others may require that you document the narrative part of your progress note using a certain format. CMBHS does not require a specific format and allows you to enter text using any format.
You are not limited on the number of characters you may enter in this text box.
To enter text into the text box, CLICK in it and begin typing.
Comment Section - This section is available for the users to add any additional comments if they have any.
Users can also add their comments based on the edits made to the Closed Complete Progress Note. This will help other users to view what changes were made in different versions.
Document Status - This drop-down field should have Draft and Closed Complete status for the users to select while saving the document.
Save- This button should be used to save the document.
Cancel- This button should be used to Cancel the changes or if the user wants to exit out of the page.
Spell Check- This button can be used to check for the spelling of the words entered.
Edit- This button will be available only to user who has Write /edit access to the page.
Progress Note History- This button should be used to check different versions of the Progress Note.
When a user makes edits to the closed complete Progress Note, the system will save it as a different version and the version history will be displayed under the Progress Note History button.
The user who has edit access to the Progress Note can only edit the closed complete Progress Note.
TMHP Validation check
General Revenue validation check:
The Psychoeducational Note is a progress note with some important differences. First, it relates to providing a specific service — educational services — whereas regular progress notes are used to document a wide range of services.
Secondly, the psychoeducational note allows you to write one note that can be added to the health record of many clients. The multi-client note type is most frequently used to document learning psychoeducational services provided to a group of clients, where the response of individual clients is not reported.
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NOTE: The Psychoeducational Note is used to document didactic psychoeducational services provided to a group of clients. Therefore, the Psychoeducational Note should not refer to any specific client because the same note will be placed in the record of multiple clients. The Psychoeducational Note allows you to write one note for many clients — a time-saver for staff, but it prevents the individualization of the note.
NOTE: The Progress Note is used for documentation whenever the client is expected to internalize, individualize, personalize, or process behavior, thoughts, feelings, information, or situations. A separate Progress Notes is completed for each client in attendance at the group session, and each note addresses only one client. Progress Notes are completed within 72 hours after the service has been provided and are used in substance use disorder documentation. |
NOTE: In CMBHS the multi-client and single client note functions are separated. The single client psychoeducational note is accessed from the Client Services Toolbar to your left, whereas the multi-client psychoeducational note is accessed from the Administrative Toolbar at the top of the CMBHS page.
Your business entity and service location must be authorized to document service delivery information in client records.
You must be assigned a role that permits you to document the delivery of services in CMBHS. Click here for a list of all CMBHS roles and the Read-Only and Read-Write Page Rights for each.
Make sure that you have a complete list of all clients who participated in the activity that you are documenting.
Determine if any of the clients in the group should be excluded from the group note or will require additional documentation.
If you identify a client that needs a unique note, use the multi-client note function to put an identical note into the record of each client you select. If you must document any individualized information about a client, create a single-client note for that client instead of including them in the multi-client note. This decreases the likelihood of complications.
The clients that will be documented must have a profile in CMBHS and a service begin for the timeframe when the session was conducted.
Before you document a note, make sure that you are familiar with the CMBHS note types so that you can select the appropriate type for your documentation needs.
| Remember: Only the person in the Performed By field or a user with the role of Clinical Supervisor can edit a Progress or Psychoeducational Note. |
From the Provider Tools menu on the Administrative Toolbar, select Provider Tools > Psychoeducational Note (Multi-Client).
The Progress Note page is displayed.
The Note Detail fields are:
Progress Note Type – This field will be pre-filled with "Psychoeducational" and cannot be edited.
Performed by – Select the name of the staff member who conducted the psychoeducational session.
Contact Type – Use this field to document the type of contact you had with
the client.
Answer choices are:
Service Location – This field is used to document the location where the service was given to the clients.
Choices are:
Funding Source – Select the appropriate funding source for billing. This field will determine which client names will be displayed for selection. One multi-client psychoeducational note will be documented for each funding source.
Service Date – Document the date that the service was provided to the client in this field. You can type in the 8 numbers for the date, mmddyyyy (e.g., 03082019) and CMBHS will format the date as 03/08/2019. Or you can type mm/dd/yyyy yourself.
Start Time – Enter the start time of the session. You can enter four numbers for the time, 0900, and CMBHS will format the time as 09:00. Or you can enter 09:00.
End Time – Enter the end time of the session. You can enter four numbers for the time, 0900, and CMBHS will format the time as 09:00. Or you can enter 09:00.
Duration – Calculated from start time to end time. Field is not editable.
Service Type – Dropdown list of service types that displays after you click the Add Service Type button. Select appropriate service type for the client. This field will determine which clients will be displayed for this section. One multi-client psychoeducational note will be documented for each service type.
Service Description – This dropdown list will be determined by the Service Type. Select the appropriate service description for the session conducted. CLICK ON your choice to highlight and select a service.You may pick only one.
Billable Checkbox – When a billable service description is selected, a checkmark will populate the billable field. Otherwise, this field will display "Not Billable."
Service Units – Defaults to the calculation based on the start and end time.
Billing Unit – Pre-filled with time unit for billing.
Topics Addressed (Required for Group Notes) – Enter topics addressed during session. This is a required field for group notes.
Session Narrative – This field is used to document the client's response to services, information that will assist other clinicians/providers in delivering the safest, most effective services to the client, and/or other information that must be documented as required by law or contract.
Your organization and others may require that you document the narrative part of your progress note using a certain format. CMBHS does not require a specific format and allows you to enter text using any format.
You are not limited on the number of characters you may enter in this text box. To enter text, CLICK in the box and begin typing.
The following are formats that can be used for the session narrative:
S.O.A.P.
• Subjective – clients observations or thoughts, client's direct
statements
• Objective – counselors observation during session
• Assessment – the counselor's understanding of the problem
and assessment results
• Plans – goals, objectives and strategies reflective of client's
needs during the assessment
C.A.R.T.
• C=client condition
• A= what action did the counselor do in response to client
condition
• R=client response to treatment plan
• T=how response related to treatment plan
B.I.R.P.
• Behavior
• Intervention
• Response
• Plan
D.A.P.
• Describe (the facts of the session)
• Assess (Evaluate client’s treatment progress toward meeting
their goals)
• Plan (Document what is going to happen next)
Clients – Clients who can be included in the note are listed alphabetically with a checkbox before each name. To include a client in the note, click inside the checkbox. Do this for each client who is to be included in the note. A checkmark will appear in the box and the note will be placed in the client's CMBHS record. Note that two buttons above the Clients section allow you to Select All Clients, or Unselect All Clients.
Document Status – select the appropriate document status. Click here for more information about document status.
If Ready for Review or Closed Complete is selected as the document status, the system will run an edit check on the required fields. A message displays indicating what, if any, field requires correction. After reading the error message, CLICK on the OK button, and you will be taken to the field that requires correction. You will continue receiving error messages until all the problems are corrected. After you have corrected all the errors, CLICK ON the Save button. The Successfully Saved message will display once all required fields are completed.
If a Successfully Saved message appears, your documentation is complete and saved to the client’s record in CMBHS.
CLICK ON the OK button to make the message box disappear.
After selecting the correct Documents Status, CLICK ON the Save button. CMBHS will save your data to the CMBHS database.
Before it saves the data, however, the system will conduct an edit check to make sure that all the required fields have been filled in properly.
If CMBHS detects an error while conducting the edit check, an Error Message will appear to inform you of the problematic field(s).
After reading the error message, CLICK ON the OK button, and you will be taken to the field that requires correction.
Correct the error then CLICK ON the Save button.
You will continue receiving error messages until all the problems are corrected. After you have corrected all the errors, the Successfully Saved message will display.
If a Successfully Saved message appears, your documentation is complete and saved to the client’s record in CMBHS.
CLICK ON the OK button to make the message box disappear.
A list of psychoeducational notes will be displayed. This list can be printed or exported to Excel. Click here for more information on exporting to Excel.
The finished multi-client Progress Note will display in each client’s health record. Go to the workspace of any of the clients, and CLICK ON Progress Notes or the View All tab to view this note.