Document Status

DESCRIPTION

Document Status is the part of Clinical Management for Behavioral Health Services (CMBHS) used to preserve the integrity of clinical and administrative documents in CMBHS and maintain a record of all additions, changes and deletions to each client health record. 

 

Business Rules

• Document status is set by the user within the limits of the roles they are assigned when their CMBHS account is opened. Some user roles are limited by law while others are limited to correspond to provider business processes.
• Before the user can save a document or close a page, a document status must be selected.
• There are 4 document statuses in CMBHS:
  • Draft
  • Ready for Review
  • Closed Incomplete
  • Closed Complete.
• Draft is the default status for most documents.
• If you do not change the document status, it will remain in Draft Status.
• Draft status ensures that users can open and close a draft document as many times as needed to complete it with out loosing data.

DRAFT

• Draft status means that the CMBHS user has started putting information into a document in the client’s health record (i.e. a screening or assessment) but must close the document before finishing.
• At a later date, the user may reopen the document and continue typing in information.
  • This process may be repeated numerous times until documentation is complete.
• Draft status is the default status for most CMBHS documents.
  • This means that the first time you work on a document, the status field will display in Draft status. It will stay in Draft status until you change the status.
• If you CLICK ON Save while typing in a document, and do not adjust the document status, the document will save in Draft status.
• All required fields do not need to be complete to save in this status. The system does not conduct a data check for Draft Status.
• Any user with a role that allows them to put client information into a CMBHS document, can put the document in Draft status if it is available for that page.
• If a Consent for Release of Information is received for a document in Draft Status, the document will not be released by CMBHS.
• If a document is in Draft status, it does not meet the system requirements.
• Documents left in Draft status for more than 30 days will be automatically be set to Closed Incomplete by CMBHS.
• A form in Draft Status can be deleted because it is not yet signed by the user and officially placed in the client’s health record.
• Only documents in Draft status can be deleted.

 

CAUTION:

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

 

READY FOR REVIEW

• Ready for Review status is used by interns and other staff whose documentation must be reviewed and co-signed by a clinical supervisor.
• A CMBHS user with this limitation is given the CMBHS role of Para-Professional. The staff that will approve the document and put it in Closed Complete status, must be given the role of Para-Professional Supervisor.
• For this document status, when the user has finished typing information into a document, he/she places the document in Ready for Review and CLICK ON Save.
• The document must then be opened by a staff with the Para-Professional Supervisor role, who reviews the document and signifies approval by putting the document in Closed Complete status and CLICKING ON Save.
• “Approved by” with the name of the Para-Professional Supervisor will display in the audit information at the bottom of the CMBHS page.
• All required fields must be complete when a document is placed in Ready for Review status because in this status, when you select Save, CMBHS will conduct an Edit Check of your documentation.
• You will receive an error message if you have missed a required field or if you typed in information incorrectly.
• For more information about the Para-Professional and the Para-Professional Supervisor role that use this status, CLICK HERE.

 

CAUTION:

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

 

CLOSED COMPLETE

• Closed Complete status is used when all data entry into a document is complete and it is ready for entry into the client’s CMBHS electronic health record.
• After selecting the Closed Complete status, then CLICK ON SAVE, no further data entry (additions, changes, deletions etc) are possible.
• The document becomes view only and no further editing of the document is possible.
• All required fields must be complete when a document is placed in Closed Complete status.
• In this status, when you select Save, CMBHS will conduct an Edit Check of your documentation. You will receive an error message if you have missed a required field or if you typed information incorrectly.
• 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.
For more information about roles that may use the CLOSED COMPLETE status CLICK HERE.

 

CLOSED INCOMPLETE

• This status is used when a document is not complete but 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.
• This status is differentiated from Draft status in that although data entry is incomplete for both, for Closed Incomplete status, the client’s circumstances are such that no further information is expected for this episode of care.
• For both Draft and Closed Incomplete status, CMBHS does not check the information the user has entered to ensure that the correct information is in the fields and that all required fields are completed.
• After selecting the Closed Incomplete Status and CLICKING on SAVE, the document becomes view only.
• A document in Closed Incomplete status can be reopened and put in Draft status for additional data entry if needed.

 

CAUTION:

REMEMBER, Documents left in Draft or Ready for Review statuses for more than 30 days will be automatically be set to Closed Incomplete by CMBHS.

 

DOCUMENT STATUS DATE

• This date field is automatically filled with today’s date by the CMBHS System.
• This date is the date that the document status is set by the CMBHS user. It is NOT the date that the services were provided to the client.
• The Document Status Date can not be changed by the user.

 

COMMENT BOX

• You may enter any additional information related to this page or the screening process for this client into the Comment box.