Page # NTS027

Psychoeducational Notes

MULTI-CLIENT PSYCHOEDUCATIONAL NOTES

The Psychoeducational Note is a progress note with some important differences. First, it relates to providing a specific service, psychoeducational 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 one client or many clients. The multi-client note type is most frequently used to document didactic psychoeducational services provided to a group of clients, where the response of specific clients will not be reported.

 

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.

 

The page # for the multi-client Psychoeducational note is #NTS027.

 

Note:

The instructions below are related to the multi-client Psycho-educational note only.

CLICK HERE for information related to the single-client psychoeducational note.

 

Before You Start

• 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.
• For more information about the CMBHS roles that have read and write access to this page, CLICK HERE.
• Remember there are 2 different types of Psychoeducational notes in CMBHS – one to document on a single client and one to document on a group of clients that attended the same psychoeducational service.
• You are currently in the Help feature for documentation of multi-client psychoeducational notes.
• Make sure that you have a complete list of the all clients that 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, there are 2 ways to document.
  1. Preferred Method – The multi-client note function puts 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 related to authorization and/or billing.
  2. Alternate Method – Complete a multi-client note on all the clients that participated, and then write an additional note, a single client note describing the client’s inappropriate behavior and the staff’s response.
• The clients must have (at minimum) a profile in CMBHS.

   

  EXCEPTION

  An Mental Health (MH) Crisis Note for Unknown Client can be completed on a client that has not given a name and therefore, may or may not have a health record in CMBHS.

• 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.
• Always verify that you have the correct client by checking the client’s name and at least one other identifier at the top of the page before you begin.

Business Rules for Multi-client Psychoeducational Notes

The multi-client psycho-education note is available from the Administrative toolbar at the top of the page, the Provider Tools group. Because the note will be for multiple clients, you do not go to the health record of a specific client. The multi-client note can be documented from anywhere in CMBHS that you can access the Administrative toolbar, Provider Tools group.

How to Document a Multi-client Psychoeducational Notes

• To Document a Multi-client Psychoeducational Note, complete the following data fields:
• Set the document status and then CLICK ON Save.

Performed By

Required for mental health and substance abuse services

• This field is used to document the name of the clinician that provided the service to the client.
• This field will be pre-filled with the name of the CMBHS user that is creating the note. Your name should display in this field.
• If you are not the person that provided the service and you are documenting for the Clinician that provided the service, select their name from the list. Use the drop-down list to display the names of all the CMBHS users at your location.
• Select the name of the person that performed the service by highlighting and CLICKING ON the correct name.
• The new name you selected will replace your name.

 

Contact Type

Required for mental health and substance abuse services

• Use this field to document the type of contact you had with the client.
• Face to Face will display as it is the default. If face to face is the correct answer for this field, you do not need to enter anything into this field.
• If you need to make a change, select an answer choice.
• Answer choices are:
  • Face to Face

    The clinician provided services to the client in person.

  • Telehealth

    A service provided by a physician (or other health care provider within the scope of their license or certification) delegation for the purpose of 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”.

    CLICK HERE for more information on Telehealth Services.

  • Telephone

    The clinician and recipient have contact by phone.

 

Recipient Type

Required for mental health and substance abuse services

• This field is used to document who received the services being documented in this note.
• If the recipient was a group of clients, select Client.
• The answer choices are:
  • Client
  • Client and Family or LAR
  • Client and other collateral
  • Collateral, LAR only
  • Collateral, not specified
  • Invalid
  • Unknown

Service Location

Required for mental health and substance abuse services

• This field is used to document the location where the service was given to the clients.
• The answer choices are:
  • Ambulance, Land
  • Community IMD
  • Community setting
  • Emergency Room
  • General medical hospital
  • Home
  • Hospital
  • Independent Laboratory
  • Inpatient Hospital
  • Inpatient Psychiatric Facility
  • Jail
  • Nursing facility
  • Office/Clinic
  • Other
  • Outpatient Hospital
  • Psychiatric Facility Partial Hospitalization
  • Psychiatric Residential Treatment Center
  • Residential Substance Abuse Treatment Facility
  • School
  • Service facility
  • State MH facility
  • State MR facility
  • State Funded community hospital
  • State or Local Public Health Clinic

     

    Other Service Location

    • If you selected Other Service Location as your answer choice, then you must provide information about that location in the text box.

 

Service Date

Required for mental health and substance abuse services

• Document the date that the service was provided to the client in this field.
• Enter the date in the text box by entering 8 numbers (mmddyyyy) and CMBHS will put them on the correct date format (mm/dd/yyyy) or you may enter (mm/dd/yyyy) yourself.

 

Start Time

Required for mental health and substance abuse services

• This is the time that the service to the client was started.
• Enter the time in the text box by TYPING IN the four (4) numbers (hhmm) representing the hour and minutes and CMBHS will put them in the correct time format (hh:mm) or you can TYPE IN the numbers and slashes yourself in this format (hh:mm).
• Next, select AM or PM by CLICKING IN the circle.

 

End Time

Required for mental health and substance abuse services

• This is the time the service to the client stopped.
• Enter the time in the text box by TYPING IN the four (4) numbers (hhmm) representing the hour and minutes and CMBHS will put them in the correct time format (hh:mm) or you can TYPE IN the numbers and slashes yourself in this format (hh:mm).
• Next, select AM or PM by CLICKING IN the circle.

 

Duration

Required for mental health and substance abuse services

• This field will fill in automatically using the Start Time and End Time information you entered in the fields above.
• Duration is displayed in Minutes.
• If the Unit Type = Hour, then Unit = Duration/60 Minutes (round-down to the closest 15 minutes. For e.g. Duration = 75 then 75/60 = 1 Unit

 

Show only open services

Not required for mental health or substance abuse services.

This is not a data field

• This function is a filter tool that makes documentation easier for the user.
  • Check this box if you want to limit the list of services that will display to only those that are currently open for this client.
  • If you do not check the “Show only open services” box, the list of services that will display will include all services offered by that location.

 

Service Type

Required for mental health or substance abuse services

• Service type describes the service to begin. In this field, document the service to begin.
• The answer choices are determined by the services provided at your location as documented on the Services Offered page SOF066 and any services that may already be authorized for this client.

 

Billable

Not required for mental health or substance abuse services

• Place a check mark in the box by CLICKING IN the box if this is a billable service.
• If the service is not billable, do nothing and leave the box empty.

 

Service Description

Required for mental health or substance abuse services

• Select an appropriate service description for the services provided to this group of clients.
• To see the list of service descriptions, CLICK ON the arrow and the list will display.
• CLICK ON your choice to highlight and select a service. You may only pick one.
• For more information about Service Descriptions CLICK HERE

 

Topic Addressed

Required for mental health or substance abuse services

• This field only displays if the note type is Counseling and the Service Description is Group Counseling.
• TYPE IN the topics discussed with the service recipients into the text box

 

Session Narrative

Required for mental health or substance abuse services

• This field is used to document information that will assist other clinicians/providers to deliver services to clients and/or other information that must be documented as required by law or contract for clinical or financial reasons.
• Your organization, payers and others may require that you document the narrative part of your progress note using a certain format.
• CMBHS does not a specific format, so you may enter text into this text box 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 the box and begin typing.

 

Next,

• After you complete the session narrative, select the clients that participated in the Psychoeducation service.
• This note will be placed into the health record of each client you select.

 

Clients

Required for substance abuse or mental health services

• CLICK ON the name of the client that you want to select for this note in the box on the left and then press the >.
• This will move the client’s name from the left to the box on the right. The note will be placed in the health record of all the clients in the box to the left.
• If you need to remove a client from the box on the right, CLICK ON the name of the client for whom you do not want to document a note, then press the <. This will move the client’s name from the right, back to the box on the left.
• A multi-client psychoeducational note will not be placed in that client’s record.
• You may select more than one client at a time by pressing the Ctrl key on your keyboard, then selecting multiple-clients by CLICKING ON the name of each client that you want to select for this note and then pressing the > or the < symbol.
• If you want to select all the clients, highlight the names of all the clients and then select the double-arrow symbol >> or <<.

 

 

Document Status

Required for mental health and substance abuse services

• Select a Document Status from the drop down list before saving your documentation.
• The Progress Note Document Status choices are:
  • Closed Complete

    CLICK HERE for information on Closed Complete status

  • Closed Incomplete

    CLICK HERE for information on Closed Incomplete status

  • Draft

    CLICK HERE for information on Draft status

  • Ready for Review

    CLICK HERE for information on Ready for Review status

 

Comments

Not required for mental health or substance abuse services

• You may enter comments in this box
• Your comments will be entered into the client’s health record and will be seen by those that have the authority to view this part of the record.
• Under some circumstances, this may include the client.
• To enter comments, CLICK IN the Comments text box and begin typing.

What’s Next?

• 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, it will conduct an edit check to make sure that all the required fields have been filled in properly.
• 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.
• 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 the Progress Notes or View All tab to view this note.
• If the CMBHS system 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.
• CLICK ON the OK box and the Progress Note will close.

How to Edit a Multi-client Psychoeducational Note

1. If you need to make a change to a Psychoeducational Note after it has been set to Closed Complete, you must go to the Workspace of one of the clients to locate the note.
2. All documents are located for viewing and editing from the document list.

From the document Tabs,

Select Psychoeducational Notes by CLICKING ON the Tab.

1. The list of Progress notes in the client’s record for this Episode of Care will display.

Find the note you need to Edit and select it by highlighting the row.

1. CLICK ON the View button and the Progress Note will display.
2. CLICK ON the Edit button in the upper right hand corner of the page.
3. Make the needed changes to data fields and CLICK ON the Save button.

NEXT,

CLICK HERE to go to 'ADMINISTRATIVE NOTE FOR MULTIPLE-CLIENTS'