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Prescriber: How to Complete the Psychiatric Evaluation

The Inpatient Psychiatric Note is a Service Note created as part of a Service. It is selectable when a procedure that calls for use of the IP Psychiatric Note and is properly linked to the note is selected as part of the creation of a service.

How to Display the IP Psychiatric Note Page

  1. With an active client selected, click the Search icon.
  2. Type ‘Service Note” into the search bar.
  3. Click to select Service Note (Client). The Service Note screen opens.
  1. Select a Program from the dropdown. Ensure the status is set to Show.
  2. Select the Inpatient Psychiatric Procedure from the dropdown.
    1. Different procedures will populate different Notes. The Note tab will initialize.
  3. Click the Note tab.

The remaining required fields and tabs will need to be completed as part of Service Note creation. For more information, see Service and Service Note training.

How to Complete the General tab of the IP Psychiatric Note for an Admission Note

  1. Begin on the Note tab of the Service Notes screen. The General tab of the note will be pre-selected.
  2. Click the IP Admission radio button to select a note type. Each note type will have a different selection of fields available. The selected note type will initialize.
  1. Click a radio button to select Child or Adult. If Adult is selected, the Child/Adolescent tab will be disabled.
  1. Complete required fields.
    1. Enter a Chief Complaint/Reason for Visit. If you have previously entered a Chief Complaint/Reason for Visit, you can select the Same as Last Visit checkbox to copy the data from the previous visit into this visit. 
    1. Click a radio button for History obtained from person present other than patient or reviewed summary of records. Enter comments if needed.
    2. Click a radio button for Side Effects. If ‘Specify’ is chosen, enter specifying comments.
    3. Click checkboxes indicating which systems were reviewed. Enter detailed comments in the Comments text field.
    1. Confirm that Allergies are properly imported. If needed, Refresh the field, or open SmartCare Rx with the Open Allery button and add client allergies. For more information, see SmartCare Rx training
    1. Select checkboxes for substances the client has a history of using. If none, check the None checkbox. Add comments to selected substances
    1. When a box is checked, a clinical problems selection window will pop up. Select a radio button for an appropriate clinical problem, then click OK. If use of the substance should not be recorded as a clinical problem, click Cancel. The selected problem will be added to the note
    1. Select a radio button for pregnancy. If appropriate, record last menstrual period.
    2. Enter text for Past History. Select a radio button for The interaction between any medical problem/treatment and psychiatric problem/treatment is:
    1. Enter text for Strengths, Barriers, and Disabilities.
    2. Select all appropriate checkboxes for Protective Factors
    1. Enter text in Other Notes, as appropriate.
    2. Ensure that the last completed Vitals assessment is displaying. If necessary, click refresh to bring up the most recent Vitals assessment, or click the Open vitals flow sheet button to complete a new Vitals assessment. For more information, see Flow Sheet training.
  1. Select the Save icon.
  2. Navigate to the next tab.

How to Complete the Exam tab of the IP Psychiatric Note for an Admission Note

  1. Begin on the IP Psychiatric Note.
  2. Select the Exam tab.
  3. Complete required fields in each section by selecting a radio button for each system. If Assessed is selected, the sections will initialize. Click each checkbox for which your exam returned significant findings. Alternately, you can select the All Within Normal Limits checkbox to set all systems to Within Normal Limits. Enter text in comment fields and select the appropriate radio buttons as they appear.
  1. Select the Save icon.
  2. Navigate to the next tab

How to Complete the Medical Decision Making tab of the IP Psychiatric Note for an Admission Note

  1. Begin on the IP Psychiatric Note.
  2. Select the Medical Decision Making tab.
  3. Complete required fields.
    1. Check boxes to indicate data you have reviewed.
    2. Enter lab order notes, and confirm previous labs are displayed appropriately. If necessary, click the Refresh button to bring up most recent labs.
    1. Check all applicable boxes in the Risk of Complications and/or Morbidity or Mortality of Patient Management.
    1. Enter Quick Orders as needed. For more information, see Orders training
    1. Review the previous plan, and update as necessary. Select a Consent radio button, enter comments in the Plan text field, and select a Level of Care justification from the dropdown.
    1. Review existing medications and update as necessary. On the Note, select from radio buttons and enter text in fields. Click SmartCare Rx, Medication History, and Orders buttons to link to other functions. For more information on adding medications and orders, see SmartCare Rx and Orders training.
    1. Complete the Suicide Risk Level section. Select Low, Medium, or High risk radio buttons for each prompt, and enter text in the Rationale field.
    1. Optionally, add a Problem section by selecting the Add Problem hyperlink at the top of the page.
    2. Select the Problem button. A pop-up will appear.
    1. Select an existing Problem from the pop-up.
    2. Click the OK button. The pop-up will close.
    1. Select a complexity from the dropdown and enter comments in the text field. Continue with the tab, or save and navigate to the next tab.
  1. Select the Save icon.
  2. Navigate to the next tab.

How to Complete the Child/Adolescent tab of the IP Psychiatric Note for a Daily Progress Note

  1. Begin on the IP Psychiatric Note.
  2. Select the Child/Adolescent Making tab. If the Child/Adolescent tab is not present, ensure that you have selected a Child/Adolescent note on the general tab.
  3. Complete required fields. For each section, select the appropriate radio button for each prompt, then enter comments in the text field
  1. Select the Save icon.
  2. Navigate to the next tab.

How to Complete the AIMS tab of the IP Psychiatric Note for a Daily Progress Note

  1. Begin on the IP Psychiatric Note.
  2. Select the AIMS tab.
  3. Complete required fields.
    1. For each section, select a score from the dropdown for each prompt. Note that previous scores will display to the right of each dropdown
    1. For the Dental section, select a Yes or No radio button for each prompt.
    2. Add Comments in the text field if needed. Note the total score will be displayed to the right.
  1. Select the Save icon.
  2. Navigate to the next tab.

How to Complete the Diagnosis tab of the IP Psychiatric Note for a Daily Progress Not

  1. Begin on the IP Psychiatric Note.
  2. Select the Diagnosis tab.
  3. Complete required fields.
    1. Search for a diagnosis code or description. Select the chosen diagnosis from the dropdown that appears when you begin entering text.
    2. Select a Type, Severity, and Remission status from the dropdowns. Enter a specifier and source in the text boxes. If desired, change the order numeral, change the Billable radio button, and/or set the diagnosis as a Rule Out by selecting the checkbox.
    3. Click the Insert button. The diagnosis will be added to the Diagnosis List.
    4. Type text into the Screening Tools Used and Other General Medical Conditions fields.
    1. In the Psychosocial, Environmental, and Other Factors section, click the Factor Lookup button. A pop-up will appear.
    1. Select any or all of the checkboxes that apply.
    2. Click the OK button.
    1. Enter Comments in the text field.
    2. If applicable, enter GAF, WHODAS, or CAFAS scores.
  1. Click the Save button.
  2. Complete any remaining tabs.
  3. Click the Sign button to sign the document according to the steps outlined in How to Sign a Document.