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Clinical Documentation

Quick Guides

EHR Essentials (PDF)

Clinical Workflow (PDF)

Intake Flow Sheet (PDF)

Common Diagnoses Codes (PDF)

Logging in to SmartCare

User Login Process

Changing Your Password

Setting up Your Security Questions

Multi-Factor Authentication

Login Help

How to Reset Your Password

How to Recover Your Username

How to Get Additional Login Assistance

Basic Navigation and Functionality

How to Use List Pages

How to Export Data

How to Sort the Columns

How to Save Filters and/or Create Favorites

How to Save Filters and/or Create Favorites

Widgets

The Caseload Widget

The Appointments For Today Widget

Tracking Widget

Screen vs. Document

Making a QuickLink

Tracking Widget

Keyphrases: Add/Edit Permission only

Client Search

How to Use the Client Search Window

How to Use the Client Search Icon

How to Use the Client Search Icon to Search to Find Client in Your Caseload

Life Cycle of the Client: Request for Services

How to Document a Referral from a Managed Care Plan (MCP)

How to Document a Referral from an Emergency Department (ED)

How to Handle Calls on a Non-Crisis Line and Client Says they’re in Crisis

How to View Requests for Services that are Pending

How do I document a request for services received via the Access Line?

How to Document Calls to the Crisis Line

How to Document a Paper Referral from a Partner Agency

How to Document When Someone Walks in for an Assessment

How to Document a Call When You Don’t Provide Services Yourself

Life Cycle of the Client: Screening

How to Complete the Adult Medi-Cal Screening Tool

How to Enroll the Client in an Access Program (Screening Setup)

How to Schedule an Intake Appointment for a Program You Manage

How to Make a Referral

How to Refer the Client to Additional Services, Such as Primary Care Physician

How to Complete a Youth Medi-Cal Screening Tool

How to Complete a BQuIP SUD Screening Tool

How to Refer to an External SUD Program

How to Refer the Client to the County’s (MHP) System of Care

How to Refer the Client to the Managed Care Plan (MCP)

How to Document Follow-up Done on an External Referral

How to Add a Provider to the Client Information: External Referral List

How to Modify a Provider to the Client Information: External Referral List

Life Cycle of the Client: Intake and Assessment

How to Add the Client to Your Program

How to Check-in a Client for their Assessment Appointment

How to View and Update the Intake Document Task List

Life Cycle of the Client: Services

How to Add an ICD-10 Code to a Service Before the Clinician Completes the Assessment and Diagnosis

How to Document Treatment Team Meetings

How to Add a Zoom or Webex Link to a Service Appointment

Service Code Definitions

Client Abbreviated Notes Report

How to Write a Progress Note for a Scheduled Service

How to Write a Progress Note for an Unscheduled Service

How to Amend a Note

How to Create a Favorite Service Note (or Other Clinical Document)

Group Documentation

Group Documentation Videos

How to Set Up a Group

How to Add a New Client to a Group

How to Add or Change a Staff Member in a Group

How to Write a Group Progress Note

Life Cycle of the Client: Discharge

How to Get a Summary of Care

How to Get a Discharge Summary

How to Close a Client to a Program

Privacy and Consents

Clinical Data Access Group (CDAG)

How do I know what CDAG I have?

What happens if I work in both SUD and MH programs?

What if the client wants me to be able to talk to other programs/people/agencies?

What happens when a client signs the Coordinated Care Consent?

What happens when a client revokes their Coordinated Care Consent?

Will I be alerted if a client revokes a consent?

Coordinated Care Consent & Authorizations to Disclose Confidential Information

How to Complete a Coordinated Care Consent

What do I do if the client wants to revoke their Coordinated Care Consent?

How to Determine if the Client has Signed a Coordinated Care Consent

How to Revoke a Standard Release of Information/Authorization to Disclose Information

How to Determine What Disclosure Authorizations (Release of Information) the Client has Signed

How to Document a Release of Information (Authorization to Disclose Confidential Information)

Other Consents

How to View What Consents a Client has Signed

Minor Consent, Conservatorship, and Guardians

How to Complete a Consent for Telehealth

How to Document a Revoked Consent

Clinical Documents

Zoom’s Remote Control Function to Obtain Signature

Mental Status Exam (MSE)

CalAIM Assessment

Child and Adolescent Needs and Strengths (CANS) Tool

Pediatric Symptom Checklist (PSC)

Pediatric Symptom Checklist (PSC)

How to View PSC scores Over Time

ASAM Assessment

ASAM Assessment

Problem List

How to Add a Problem to the Problem List

How to Remove a Problem That’s Been Resolved

How to Add Favorites to the Problem List Screen

How to Filter/Sort a Client’s Problem List

Care Coordination

How to Document Treatment Team Meetings

How to Request Authorization for Services

How to Refer to an Additional Program

How to Refer the Client to Additional Services, Such as Primary Care Physician

How to Transfer the Client to the MCP

How to Document Follow-up Done on an External Referral

How to View Who’s on the Client’s Treatment Team

How to See Who’s On My Caseload

Group Documentation

Group Documentation Videos

How to Set Up a Group

How to Add a New Client to a Group

How to Add or Change a Staff Member in a Group

How to Write a Group Progress Note

Diagnosis Entry

How to Add a Diagnosis

How to Save a Favorite Diagnosis

Reordering Diagnoses List

How to Modify and/or Re-Order a Diagnosis

How to Modify a Diagnosis After the Document is Generated

How to Pull a Diagnosis Forward from Another Program

How to Delete a Diagnosis

State Reporting

CSI

How to Complete a CSI Demographic Record

How to Complete a CSI Assessment Data Record

CalOMS

CalOMS FSN Work-Around

How to Complete a CalOMS Admission

How to Complete a CalOMS Referral/Transfer

How to Complete a CalOMS Discharge

Full-Service Partnership (FSP)

Full-Service Partnership (FSP)

How to Complete a PAF

How to Complete a KET

How to Complete a 3M

My Calendar Management

How to Create an Appointment from Your Calendar

How to Create a Recurring Individual Service Appointment

How to Reschedule a Client’s Appointment

How to Cancel a Client’s Appointment

How to Document a No-Show Appointment

How to Document Additional Information for a Scheduled Appointment that Results in a No-Show

How to Schedule Non-Client Time

How to Schedule Non-Client Time on Your Calendar

Other Functionality

How to Print a Client Face Sheet

How to Complete a NOABD

How to Attach a Document to a Service Note

How to Enroll a Client in Text (SMS) Appointment Reminders

How to Open the Caseload List Page

How to View My Caseload

How to Create a Flag to Alert Treatment Team Members to Important Client Information

How to Scan or Upload Documents into the Client’s Record

How to Print a Document to Get a Client’s Signature

How To Identify a Client as Katie-A or Other Special Population

How to Attach a Document to a Service Note

How to Manually Add a Tracking Protocol to a Client

How to Manually Remove a Tracking Protocol from a Client’s Record

Messaging in SmartCare

How to Send a Message

How to Send a Document in a Message

Error Correction Processes

Service Note Errors

How to Fix an Error on the Service Note if You Have Signed It Already

I wrote a duplicate service note. How can I delete it?

I wrote a service note under the wrong client. How do I move it to the correct client?

I wrote a group service note but I forgot to update the participant/facilitator list. How do I fix it?

Error Reporting - When You Can't Fix it Yourself

How to Report a State Reporting Error

How to Report an Individual Service Note Error

How to Report an Error that Needs to be Corrected

Supervisor Workflows

How to Sign Documents in a Batch

How to Change the Author of a Document

How to Reassign Cases in a Batch

Revision Tracking

Revision Tracking