Documenting in CMBHS

CMBHS provides a number of ways to enter information. These include typing in text boxes, clicking on choices in dropdown lists, and clicking in check boxes. The goal of these methods is to ensure accurate data for everyone who uses the system.

Prior to entering data into CMBHS, always check client identifiers before beginning to document. Also check that you are in the correct provider location and that you are in the correct client’s health record. Both pieces of information can be found at the top of CMBHS pages.

If you document or perform a function incorrectly, CMBHS may display an error message. Re-entering the information may help. If this does not help and you find that you need additional assistance, call the CMBHS Helpline at 1-866-806-7806.

 

Click here for Help on entering information into CMBHS.

 

Click here for Help on Page Setup.

 

Click here for Help on Document Status.


Entering Information in CMBHS

Radio buttons

How to use radio buttons:

  • CLICK inside the circle to select. A black dot will appear in the circle indicating that you have successfully chosen the item.
  • To remove the dot, CLICK inside the same circle again.
  • Once you CLICK in a circle and have made a choice, you may change your choice, but you can no longer leave the item blank. You must pick one of the answer choices.

 

Dropdown Lists

How to use dropdown lists:

  • CLICK on the arrow on the right of the box to show the list of answer choices. If needed, use the scroll bar on the right to show all the items.
  • CLICK on the item you wish to choose. You can select only one answer.
  • The item will be highlighted to show that you have successfully selected the item.
  • Some dropdown lists are multi-select lists. To make a second, or more, selection, hold down the CTRL key while you CLICK on the desired additional choice/s.

 

CAUTION: When using dropdown lists, as long as an answer choice is still highlighted, it can be accidentally changed by the user. This is especially true if you use your mouse's scroll wheel. To make sure that your answer does not accidentally change after selection, CLICK outside of the dropdown list anywhere on the CMBHS page to “set” your answer.

 

Choosing “Other” in a List

How to pick “Other” as an answer in CMBHS:

  • In some dropdown lists, Other is provided as an answer choice.
  • Most of the time, CMBHS requires you to provide additional information to explain why you picked Other. This is when you must TYPE in additional information.
  • Whenever Other is chosen, a text box may appear. Type the required additional information into the text box and then CLICK the Save button. If you do not add text, you will get an error message telling you to provide the required information before attempting to save the document.

 

Check boxes

How to use check boxes:

  • CLICK inside the box.
  • To change your choice, CLICK your first selection to clear the box, and then CLICK in the appropriate check box.

 

Text box

How to use text boxes:

  • Most text boxes in CMBHS will accept both numbers and letters. If only one kind of character (numbers or letters) is accepted in a text box, this will be explained next to the text box.
  • When using a text box, look for information that indicates the number of characters you may type into the text box, and adjust your documentation to fit that limit.
  • If you type excessive characters, the system stops displaying the characters you type and you will get an error message when you try to save your documentation.

 

Date Text boxes

How to Document the Date in CMBHS:

To put dates into CMBHS, TYPE in the eight numbers that represent the date and CMBHS will format the date with forward slash marks dividing the month, day, and year.

If you prefer, you may TYPE in the date in the final format with a forward slash between the month and day and between the day and year.

If the month or day is 9 or less (a single digit number) insert a zero before the month or day.

Example 1: The date is February 9, 2019. TYPE in 02092019.

  • CMBHS will format the date correctly – 02/09/2019

Example 2: The date is December 12, 1960. TYPE in 12121960.

  • CMBHS will format the date correctly – 12/12/1960

You can type in the forward slashes in dates yourself if you like.

 

Errors Documenting the Date in CMBHS

If you do not type in enough numbers, if you type in too many numbers, or if you accidentally enter a letter, you will get an error message.

If you type in a date that is before or after the correct date, you will receive an error message.

You cannot save a document in Closed Complete or Ready for Review until all errors are corrected.

 

How to Document the Time in CMBHS:

To put the time into CMBHS, TYPE into the text box the four numbers that represent the hours and minutes. CMBHS will auto-format the numbers.

And then, CLICK in the AM or PM radio button.

If the hour or minutes are 9 or less, (a single digit number) insert a zero before the number.

If you prefer, you may TYPE in the time in the final format with a colon between the hour and minute.

Example 1: The time to document is 2:25 PM

  • TYPE in the numbers “0225” and then CLICK PM
  • CMBHS will display 02:25 PM

Example 2: The time to document is 11:09 AM

  • TYPE in the numbers “1109” and then CLICK AM
  • CMBHS will display 11:09 AM

 

Errors Documenting the Time in CMBHS

If you do not enter enough numbers, if you put in too many numbers, or if you accidentally include a letter, you will get an error message.

If you type in a time that is before or after the correct time for that field, you will also receive an error message.

You cannot save a document in Closed Complete or Ready for Review until all such errors are corrected.

 

Transfer List Box

How to use transfer list boxes

  • To select multiple items listed one after the other, CLICK on the first item, and then SHIFT – CLICK on the last item in the series you want to select.
  • To select multiple items that are scattered throughout the list, CTRL – CLICK on
    each item.
  • Type the first letter of the item you wish to pick in order to scroll down to it quickly.

 

Transfer Symbols

> CLICKING on this symbol moves the items you have picked from the list of available items, to the box on the right, making it a selected item.

< moves items from Selected Options box on the right to the Available Options box on the left.

>> moves all items from the Available Options on the left to Selected Options on the right.

<< moves all items from Selected Options on the right to Available Options on the left.



CMBHS Page Setup

The CMBHS application is split into two primary frames or windows. On the left side of the page is the Client Services Toolbar. This menu offers a wide range of choices when documenting a client’s case. When you make a selection from this menu, it populates the larger frame to the right.

The larger window on the right side of the screen displays details of the client’s Electronic Health Record (EHR) and all other pages of CMBHS. The selections you make from the Client Services Toolbar, and from the Administrative Toolbar at the top of the right-side frame, determine what is displayed in the right-side window.

You can hide the menu toolbar frame on the left by CLICKING anywhere on the blue line that separates the two frames, or on the double arrow symbols in the middle of the line. You can redisplay the left-side menu by clicking the blue line or the double arrows again.

A scroll bar at the right side of the right window allows you to move from the top to the bottom of the page and back. If your mouse has a scroll wheel, you can also use that to scroll up and down the page.

 

Documents with Tabs at the Top

In CMBHS, many documents have multiple tabs at the top, each with a different label. As you move from tab to tab, the screens change but you are still in the same document.

You can move from tab to tab by CLICKING on the tab you want to go to without saving, or by first CLICKING on the Save button, ensuring the data you have already entered will not be lost.

You must CLICK on the Save button before leaving the document or your data will be lost.

 

Audit Information

After the page has been saved, the Audit Information fields below will be automatically populated by CMBHS and displayed.

After the document has been saved and added to the CMBHS database, the following Audit Information will show at the bottom of the page. (This information is view only and cannot be changed by the user.)

  • Created by: The name of the user who first started the document will display here.
  • Created Date: This is the date the document was first started.
  • Last Saved by: The name of the user who last opened, edited, and saved the document will display here. This field is updated each time the record is edited and saved.
  • Last Saved Date: The date the document was last opened, edited, and saved. This field is updated each time the record is edited and saved.

 

 


Page Buttons

The following list describes the buttons and page controls found on the pages of the Clinical Management for Behavioral Health Services (CMBHS) system and how to use them.

Add – this button inserts text into a table, list, or field. If you type text into CMBHS and forget to CLICK the Add button, the text will not be entered into the system. If the text is required, you will not be allowed to save the page and will receive an error message. Check to make sure that you CLICKED on the ADD button, if one is present, after entering information.

Attachments – use this button to attach a PDF document, no larger tham 10 MB, to a client's document.

Calculate – click this button to run the calculation routine.

Cancel – closes a page without saving any of the data typed into the page or selections you made since the page was last saved. A message will display to confirm you want to take this action. After clicking on Cancel, you will return to the previous page in the workflow.

Clear – most often used with search functions, this button removes any data that has been entered into the fields on a page. You will remain on the same page and can begin entering new search data.

Close – this button is used to close a document after you have viewed or saved it. 

Delete – use this button to delete a document in CMBHS. The delete function depends on the document. Please see the specific document type section in CMBHS Help for more information.

Edit – this button opens a document so that changes may be made and/or new information added.

List – CMBHS often provides information to users in lists and tables. If the list is long, additional pages will be indicated by a series of numbers at the bottom of the page.

  • To move to the beginning of the list (the first page) CLICK on the <<.
  • To move to the end of the list (the last page) CLICK on the >>.
  • To move to a specific page, click on the page number.
  • To move to the next group of pages, CLICK on the ...

 

New – opens a section of a document for data entry.

Next – allows the user to move to the next page without going through a data check/validation process.

Previous – takes you to the page in the CMBHS you were on previous to the current page.

OK – CLICKING on this button will cause the action stated in the message to take place. 

Remove – this button removes a field or a line from CMBHS. First it will display as crossed–out. After you Save, the content will be removed.

Replace – puts an entry you have removed back into view.

Save – when you pick the Save button, CMBHS validates you have completed all required fields. A message displays if you miss a required field. Once the page is filled out correctly and all the data passes the edit check, Save will save the record.

Save and Continue – saves the information you have entered, and the document remains in edit mode.

Save and New – this button allows the user to save information that has been entered, and opens a new section of the same type for data entry.

Save and Next – saves the information you have entered and moves to the next tab. 

Spellcheck – begins the spellcheck process for the page you have open.

Undo – performs the same function as Delete.

Version History – this button is used to view the history of a document. You can see older versions to identify when changes were made and who made them.

View – allows you to see documents and pages in CMBHS. To use this button, select an item by highlighting it and then CLICK on the button.

 


Read-Only and Read-Write Views

Depending on the CMBHS role(s) you are assigned, you are granted either Read-Only or Read-Write access to various pages and functions within CMBHS. Click here for a list of CMBHS pages, and what roles have Read-Only or Read-Write access to them.

 

Read-Only

In the Read-Only view, the user can look at documents but cannot create a new document, add information, or change information that has been entered in the document.

In Read-Only view, the information that has been entered in CMBHS cannot be changed or new information added. To ensure this, if you have Read-Only access to a page, the Edit button will not display on that page.

 

Read-Write

Users with Read-Write access to a page can create new documents, add information, and change information that has been entered in a CMBHS document. (The page must be in a status permitting write access.)

Most new pages of client services documentation are created using the menu on the left side of the page, the Client Services Toolbar.

Since most pages open in the Read-Only view, the user must CLICK the Edit button to make changes or add new information to the page. The Edit button is usually located in the upper right corner of the page.

Click here for a listing of CMBHS Roles and Page Rights.


Document Status

Document Status is one method used by Clinical Management for Behavioral Health Services (CMBHS) to preserve the integrity of clinical and administrative documentation. Document Status assures the user that documentation entered into CMBHS is saved in the correct status.

CMBHS maintains a record of all changes to document status, including additions and deletions to each client health record, as well as who made them.

The most recent change to document status displays at the bottom of some CMBHS pages in a box labeled Audit Information.

 

Document Status Facts

Users can set a document's status within the limits of the roles they are assigned in CMBHS. Some user roles are limited as required by law, while others are limited to adhere to provider business practices, or to protect client confidentiality.

When a user saves a document, it remains in the default Draft status unless the user picks a different status. There are four document statuses in CMBHS: Draft, Ready for Review, Closed Incomplete, and Closed Complete.

 

Draft status

Draft is the default status for most documents. Draft status ensures that users can open and close a document as many times as needed to complete it without losing data.

Documents left in Draft status for more than 30 days will automatically be set to Closed Incomplete by CMBHS.

All required fields do not need to be complete to Save in Draft status.

CMBHS will not release a document in Draft status, even if a consent for the release of information has been received.

 

Ready for Review

Ready for Review is a status used by intern paraprofessionals (such as intern LCDCs) before a document is reviewed by a paraprofessional supervisor and can be saved as Closed Complete.

When a document needs to be signed by a client, Ready for Review is the appropriate status for the document. This allows the document to be printed, signed by the client and staff, and saved in the client's file. After these steps, the document can be placed in Closed Complete.

All required fields must be completed before saving a document in Ready for Review. An error message will appear if the required information is incomplete.

Documents left in Ready for Review status for more than 30 days will automatically be set to Closed Incomplete by CMBHS.

 

Closed Complete

Closed Complete status is used when all data entry for a document is complete and it is ready for entry into the client’s CMBHS electronic health record (EHR).

After a document is saved as Closed Complete, no further data entry (additions, changes, or deletions) is possible. The document becomes view only and no further editing can be done.

In this status, all required data fields must be complete and correct when you pick Save, or you will receive an error message.

If the user needs to make a change to a document after it has been placed in Closed Complete status, an update or a new version must be created.

 

Closed Incomplete

Closed Incomplete is used when a document is ready for closure because it cannot be completed. Closed Incomplete status indicates that although the user may not have completed all required data entry, no further information is expected.

CMBHS does not validate the data or check to ensure that all the required fields are complete in Closed Incomplete status, same as in Draft status.

A document in Closed Incomplete status can be reopened and put in Draft status for additional data entry if needed.