**This is for CalMHSA Rx Users ONLY**
A new Psych/ Medical Note template has been created for medical staff. The highlights of this note template are:
- Ability to push from certain sections of the previous “Psychiatric Note” template.
- Ability to retain previous note’s information so that authors can review what was written previously and push important medical information without having to retype.
- Pull real-time objective data such as vitals, allergies, labs and medications/orders.
- Keyphrase functionality can be leveraged to create custom text template within the textbox fields to create custom text template within the textbox fields
- Flexibly select relevant sections pertinent to the visit and document efficiently via customized text templates by individual or clinic/unit.
- Allow for documentation of medication consent.
How to Get to the Psych/Medical Note
- With an active client selected, click the Search icon.
- Type Services/ into the search bar.
- Click to select Services/Notes (Client). The Service Note screen opens.
- Click the New icon.
- This will take you to the Service Note screen. Complete the Services tab.
Note: fields with an asterisk * will show up on your final PDF.
- Status*
- Program*
- Procedure*
- Location*
- Mode of Delivery
- StartDate*
- Start Time*
- Travel Time (if needed)
- Documentation Time
- Service Time*
- Attending (if needed)*
Note: The same requirements will apply for marking Status, Program, Procedure, Location, Mode of Delivery, Start Date, Start Time, and Face to Face Time.
A new feature is allowing for a supervisor’s name to be selected as “Attending,” and this will show on the final pdf. If there needs to be other co-signers, then please follow instructions to assign co-signers. CLICK HERE for the article.
- Click the Note Tab.
To see what procedure codes are defaulted to be associated to the new Psych/Medical Note template CLICK HERE. You will need to be permissioned and licensed to use these procedure codes.
Required fields:
- There are only two fields required in the template, which are the “Subjective/CC/HPI/Notes” and “Assessment and Plan.” These sections are denoted with a red asterisks (*). You will get a validation error and not be able to sign if these are not filled out (for example, if you do not want to add any additional info, you can write “N/A”. This is intentionally designed because these two text boxes have data that may be used in other documents/ reports/ services within the EHR (e.g. Abbreviated Notes Report).
How data from this template is stored and pushed to subsequent notes:
With this new template, every textbox section will pull the most recent data that has been saved (even in draft form) or signed as a final PDF. It will push that information to the subsequent note as long as it is the same client, same author, and program.
Subsequent notes will initialize the textbox field data if you click “Save” or “Sign” and did NOT have a checkbox mark for “Delete from the Note.” It will indicate when this data was last updated in case you need to reference back to a p “Sign” and did NOT have a checkbox mark for “Do not include in PDF.” It will indicate when this data was last updated in case you need to reference back to a particular note. (see image below)
- If a different procedure code is used and the Psych/Medical Note template is used for those codes, the information will still carry over.
- Objective data/tables will follow CDAG rules, except where CDAG does not apply within SmartCare already (e.g. medications, allergies)
"Delete from Note" Functionality
- This functionality was created to allow you to select only the sections relevant to the note and maintain a preview of information that may be historically important. This is done with the goal to avoid “chart bloat.”
- If “Delete from the Note” is selected for specific section, then that data will not show up on the signed PDF. If you would like to preview the note, click on “Hide PDF Sections.” If you would like to view all sections, then click “Show PDF Sections.” There is a checkbox called “Select ALL Do Not Include in PDF/Delete from the Note” which will allow removal of all sections except for the required sections “Subjective/CC/HPI/Notes” and “Assessment and Plan.”
- If “Delete from the Note” is selected, then the textbox sections will NOT save once signed. If saving is desired, then you MUST REMEMBER to remove the checkmark. Checkmarks will be retained for subsequent notes.
Refresh of Data and Tables
- While we recommend saving drafts often, the objective data will refresh every time you go to a different SmartCare screen. For example, if you go to enter a new Diagnosis Document, then this information will push into the note, when you return to screen even if the note has not yet been saved.
- Currently, Allergies, Medications and Home Medications sections are not pulling data back from CalMHSA Rx into the psych medical note template.
Note: CalMHSA is planning on a manual refresh option in the future.
Subjective/CC/HPI/Notes Section
This section can be used to capture the subjective part of a patient visit. This is mandatory to fill out. It can also be used to record chief complaints and if you choose not to document using any other sections, you can store the history of present illness and/or other notes here.
Client History and Pertinent Information
This section can be used to capture the patient’s history such as their previous psychiatric, medical, medication, or program history. It can also be used to capture any social, substance use, family history, pertinent tests. The “Delete from Note” functionality can be utilized.
Recent Labs/Tests
This section pushes two months of lab data into the note. It includes the lab name, result date, if any abnormality (H = high, L= low, N=Normal), the lab value, the range, lab comments, and if it has been reviewed by staff. The “Do Not Include in PDF” functionality can be utilized. If you do not wish to view comprehensive labs trends, then we recommend using the Comprehensive Lab Flowsheet Report. The “Do Not Include in PDF” functionality can be utilized.
Allergies/Intolerances/Failed Trials
Currently, the allergies from CalMHSA Rx are not set up to pull back into psych medical note template. The workaround can be found here. You could add this information manually under the “Client History & Pertinent Information” section.
Note: CalMHSA is working to fix this shortly.
The “Delete from the Note” functionality can be utilized.
Current Medications
Currently, the medications from CalMHSA Rx are not set up to pull back into psych medical note template. The workaround can be found here. You could add this information manually under the “Client History & Pertinent Information” section or the “Assessment and Plan” section.
Note: CalMHSA is working to fix this shortly.
The “Delete from the Note ” functionality can be utilized.
Note Regarding Medication Consent: In most situations, a separate, signed “Medication Consent” document is no longer required. Consents for medications can be captured/documented in the prescriber’s progress note. These recommendations are specific to consents for medications and not general informed consent/consent to treat.
To review the CalMHSA protocol and memo by Manatt, click here. You can also find the vetted templates and suggested use cases.
CalMHSA Rx e-prescribing system, please follow this workflow for medication consent documentation.
Current Self-Reported Medications
Currently, the home/self-reported medications from CalMHSA Rx are not set up to pull back into psych medical note template. The workaround can be found here. You could add this information manually under the “Client History & Pertinent Information” section or the “Assessment and Plan” section.
Note: CalMHSA is working to fix this shortly.
The “Delete from the Note” functionality can be utilized.
Vitals
This section will pull the last 3 vitals within a CDAG from the “Vitals/Meaningful Use” Flowsheet or “Enter Vitals”. This information will refresh the note automatically with any added information. The “Do Not Include in PDF” functionality can be utilized.
MSE/PE
This is a section that can be used to document the Mental Status Exam or Physical Exam. Key Phrases can be customized to create MSE templates to improve efficiency. The “Do Not Include in PDF” functionality can be utilized.
AIMS Completed During Visit
- There is also a checkbox to indicate if AIMS has been completed and the date will be displayed on the Client Medical Facesheet as a way to help other users know when it was last completed. The actual data collection should be completed in the AIMS Assessment Document. This checkmark will NOT be retained for the subsequent note.
Assessment & Plan
This section can be used to capture the Assessment / Plan. It is mandatory to fill this out.
Documentation of the date that the CURES database was reviewed can be marked by end user tohelp other users know when the last time this was completed. This information will be displayed on the Client Medical Facesheet as an efficient way to see when it was last completed and by whom. This checkmark will NOT be retained for the subsequent note.
Add to Shared Care Plan: This is optional as we are still building out a future-state Shared Care Plan to be more collaborative and efficient in data collecting and data sharing. The goal is that for facilities that use a shared care plan or treatment plan, individual’s plans can feed into the document to reduce the need for double entry. For now, if the box is checked, this saves to the Shared Care Plan Report which is a compilation of individual’s psych medical note’s plans. This checkmark will NOT be retained for the subsequent note. Click Here for more information.
Active Diagnoses and Problem List within Programs
This section captures the client’s diagnoses and problem list from any programs that are within the same CDAG. The active diagnosis captured by Diagnosis Document is included in the diagnosis sub-section. Also, any problems that are documented in the Client Problem List are demarcated in the second subsection. Any common ICD10s are grouped together. The date represents the most recent entry for that ICD10 code. You can checkmark the issues that were addressed at the visit. Any selection will NOT retain its checkmark for the subsequent note.
Additional Information
This section is a flexible section for authors to capture information that does not fit in any above section but should be included. (For example: attestation, client’s timeline within the program, family conversations, follow-up information). The “Do Not Include in PDF” functionality can be utilized.
Complete Note
To complete a note, the author must sign the note by clicking the “Sign” blue button on the upper right corner. The proxy and cosign workflow remains unchanged. Your document will generate.
